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PRACTICAL TREATISE 



ON 



FRACTURES AND DISLOCATIONS, 



BY 



FRANK HASTINGS 'HAMILTON, A.M., M.D., LL.D., 

SURGEON TO BELLEVUE HOSPITAL, NEW YORK ; CONSULTING SURGEON TO HOSPITAL FOR RUPTURED AND 

CRIPPLES; TO ST. ELIZABETH HOSPITAL, ETC. ; AUTHOR OF A TREATISE ON MILITARY SURGERY 

AND HYGIENE, AND OF A TREATISE ON THE PRINCIPLES AND PRACTICE OF SURGERY. 



FIFTH EDITION, 
REVISED AND IMPROVED. 



I 



ILLUSTRATED WITH 

THREE HUNDRED AND FORTY-FOUR WOODCUTS. 



l\l 




lX'~ 



PHILADELPHIA: 

HENEY C. LEA. 

187 5. 

T 



0\ 



Entered according to Act of Congress, in the year 1875, 

By HENRY C. LEA, 

In the office of the Librarian of Congress, at Washington, D. C. 

All rights reserved. 



SHERMAN & CO., PRINTERS, PHILADELPHIA. 



PREFACE TO THE FIFTH EDITION. 



The author may be permitted to express his gratification that this 
work, to which he has given so large a portion of his active life, con- 
tinues to meet with the approbation of his professional brethren, as 
shown in the demand for a fifth edition. In this alone he finds a 
sufficient compensation for all his labor. 

The present edition has been carefully revised ; many observations 
of practical surgeons, both at home and abroad, have been added, and 
the number of pages and of woodcut illustrations have been increased. 

From the first it has been the intention of the author to declare, in 
the most faithful and conscientious manner, precisely how much, with 
the knowledge and appliances at our command, we were able to ac- 
complish. This was absolutely necessary if we proposed to lay a 
proper foundation upon which we might afterwards hope to build suc- 
cessfully. Indeed, it is apparent that, if we would make of surgery 
an exact science, we must apply to its study the same exact rules 
which are alone employed successfully in the study of other sciences. 
Every false or loose statement retards our progress, or renders our 
steps hesitating and unequal. 

In reference especially to the Diagnosis and Treatment of Fractures 
and Dislocations, the reader will find that in many respects the opin- 
ions and practice of Surgeons have changed within the last fifteen or 
twenty years, and there can be no doubt that most of the changes con- 
stitute real improvements ; but there remains, unfortunately, much to 
be accomplished, so much, indeed, that no one who thoroughly under- 
stands the facts, and feels an interest in this branch of our science, 
will rest satisfied with what has been done, and hereafter cease to 
labor. 

Frank H. Hamilton. 

New York, September 10th, 1875. 



PREFACE TO THE FIRST EDITION. 



The English language does not at this moment contain a single com- 
plete treatise on Fractures and Dislocations. The two small volumes 
of Desault, and the one of Boyer, issued near the close of the last cen- 
tury, and translated into English early in this, may perhaps properly 
enough have been regarded as complete treatises at the time of their 
publication, but they certainly cannot be so considered now. The 
several chapters on "Diseases and Injuries of the Bones/' contained in 
the Legons Orales of Dupuytren, translated in 1846, and the Treatise 
on Fractures in the Vicinity of the Joints, and on Certain Forms of Acci- 
dental and Congenital Dislocations, by Robert Smith, are invaluable 
monographs, but neither of them claims to be anything more than a 
collection of occasional and miscellaneous papers. The writings of 
Amesbury and of Lonsdale relate only to fractures. Even the justly 
celebrated quarto of Sir Astley Cooper is no more than what its title 
plainly declares it to be, A Treatise on Dislocations and on Fractures of 
the Joints; but since the announcement of the present volume, a trans- 
lation of Malgaigne's great and crowning work on Fractures and Dis- 
locations has been commenced by Dr. Packard, of Philadelphia, and 
the first volume has been placed in the hands of the American profes- 
sion. Should the remaining volume be rendered into English, the gap 
in our literature will be measurably filled. 

Under these circumstances I might scarcely have thought it worth 
while to continue my labors, already so near their completion, had it 
not seemed to me that Malgaigne, whose researches have been truly 
marvellous, had failed in some measure to give a just representation of 
the observations and improvements which have been made from time 
to time by my own countrymen. 

The contributions of American surgeons to this department had to 
be sought chiefly in medical journals, many of which have long been 
discontinued, and most of which were inaccessible to the great French 
writer. Even to an American, the labor of exhumation from archives 
hitherto almost unexplored has not been small ; and it is probable that 



VI PREFACE TO THE FIRST EDITION. 

many valuable papers have been overlooked; indeed it is impossible 
that it should be otherwise. 

I am free to say, also, that I have been encouraged by a hope that 
my own personal experience, obtained during many years of public and 
private service, might be of some value to my contemporaries. 

Very little space has been devoted to what is now only historical, 
except so far as was necessary to correct certain time-consecrated errors, 
or to confirm and illustrate the practice of the present day ; but by a 
pretty full report of characteristic examples, selected from more than 
one thousand cases already published by myself, by copious references 
to the examples recorded by others, and by a careful exclusion of what- 
ever has not been confirmed by experience or established by dissection, 
I have endeavored to make this treatise useful both to the student and 
practical man, and a reliable exponent of the present state of our art 
upon those subjects of which it treats. 

In order to render the description of the various forms of apparatus 
employed in the treatment of fractures more intelligible, and to avoid 
the necessity of lengthened explanations, a large number of illustra- 
tions have been introduced, more, perhaps, than might be thought 
necessary, especially as in several instances the apparel which is figured 
is not that which is recommended by the author. It is believed, how- 
ever, that by a study of the principal forms of approved dressings the 
reader will be better prepared for the exigencies of practice ; and that 
by the simultaneous presentation of those which are not approved, he 
will be saved from a wasteful expenditure of his time in the contriv- 
ance of useless apparatus. It is not in the discovery and multiplica- 
tion of mechanical expedients that the surgeon of this day declares his 
superiority, so much as in the skilful and judicious employment of 
those which are already invented. 

The author desires to acknowledge his indebtedness to very many of 
his professional brethren, throughout the United States, for the prompt- 
ness with which they have responded from time to time to his inquiries, 
and for the generosity with which they have opened their pathological 
collections and placed valuable specimens at his disposal. 

He wishes also to express his special obligations to Dr. J. R. 
Lothrop, of this city, who has kindly aided him in revising most of 
the proof-sheets as they have been issued from the press. 

Frank H. Hamilton. 

Buffalo, N. Y., December, 1859. 



CONTENTS. 



PART I. 

FRACTURES. 
CHAPTER I. 

PAGE 

General Diyision of Fractures, 27 

CHAPTER II. 
General Etiology of Fractures, 29 

CHAPTER III. 
General Semeiology and Diagnosis, 33 

CHAPTER IV. 
Repair of Broken Bones, 38 

CHAPTER V. 

General Treatment of Fractures, 44 

CHAPTER YI. 
Delayed Union and Non'-Union of Broken Bones, 63 

CHAPTER VII. 

Bending, Partial Fractures, and Fissures of the Long Bones, . . 74 
$ 1. Bending of the Long Bones, ........ 74 

\ 2. Partial Fractures of the Long Bones, .78 

I 3. Fissures, 86 

CHAPTER VIII. 

Fractures of the Nose, 91 

§ 1. Ossa Nasi, 91 

\ 2. Fractures and Displacements of the Septum Narium, . . . .96 



VUl CONTENTS. 

CHAPTER IX. 

Fragtures of the Malar Bone, . 



CHAPTER X. 

Fractures of the Upper Maxillary Bones, 102 

CHAPTER XI. 

Fractures of the Zygomatic Arch, 107 

CHAPTER XII. 
Fractures of the Lower Jaw, HI 

CHAPTER XIII. 
Fractures of the Hyoid Bone, 137 

CHAPTER XIV. 

Fractures of the Cartilages of the Larynx, 141 

I 1. Thyroid Cartilage, 141 

§ 2. Thyroid and Cricoid Cartilages, 142 

I 3. Cricoid Cartilage, 144 



CHAPTER XV. 



146 
146 
148 
149 
154 
156 
158 



Fractures of the Vertebra, 

\ 1. Fractures of the Spinous Processes, . 
$ 2. Fractures of the Transverse Process, . 
§ 3. Fractures of the Vertebral Arches, 
g 4. Fractures of the Bodies of the Vertebras, 

1. Fractures of the Bodies of the Lumbar Vertebra 

2. Fractures of the Bodies of the Dorsal Vertebras, 

3. Fractures of the Bodies of the five lower Cervical Vertebras, . 158 

4. Treatment of Fractures of the Bodies of the Vertebras, . . 161 

\ 5. Fractures of the Axis, 164 

§ 6. Fractures of the Atlas, 167 

\ 7. Fractures of the first two Cervical Vertebras (Atlas and Axis) at 

the same time, 168 



CHAPTER XVI. 

Fractures of the Sternum, 169 

CHAPTER XVII. 

Fractures of the Ribs and their Cartilages, 175 

\\. Fractures of the Ribs, 175 

§ 2. Fractures of the Cartilages of the Ribs, 180 



CONTENTS. IX 



CHAPTEE XVIII. 

PAGE 

Fractures of the Clayicle, 182 



CHAPTER XIX. 

Fractures of the Scapula, 209 

§ 1. Fractures of the Body of the Scapula, 209 

| 2. Fractures of the Neck of the Scapula, .214 

§ 3. Fractures of the Acromion Process, ....... 215 

§4. Fractures of the Coracoid Process, 219 

CHAPTER XX. 

Fractures of the Humerus, 221 

§ 1. Fractures of the Head and Anatomical Neck, 223 

\ 2. Fractures through the Tubercles, 227 

\ 3. Longitudinal Fractures of the Head and Neck, or Splitting off of the 

Greater Tubercle, 227 

\ 4. Fractures through the Surgical Neck (including Separations at the 

Upper Epiphysis), 229 

\ 5. Fractures of the Shaft below the Surgical Neck, and above the Base 

of the Condyles, 246 

§ 6. Fractures at the Base of the Condyles (including Separations of the 

Lower Epiphysis), 257 

§ 7. Fractures at the Base of the Condyles, complicated with Fracture 

between the Condyles, extending into the Joint, . . . . 264 

§ 8. Fractures of the Internal Epicondyle, 268 

\ 9. Fractures of the External Epicondyle, ...... 272 

§ 10. Fractures of the Internal Condyle, 272 

§'11. Fractures of the External Condyle, . 275 

CHAPTER XXI. 

Fractures of the Radius, 279 

CHAPTER XXII. 

Fractures of the Ulna, 311 

I 1. Shaft of the Ulna, 311 

§ 2. Coronoid Process of the Ulna, 315 

I 3. Fractures of the Olecranon Process, 324 

CHAPTER XXIII. 

Fractures of the Radius and Ulna, 332 

CHAPTER XXIY. 

Fractures of the Carpal Bones, 343 

CHAPTER XXV. 

Fractures of the Metacarpal Bones, 344 



CONTENTS. 



CHAPTER XXVI. 

PAGE 

Fractures of the Fingers, 347 

CHAPTER XXVII. 

Fractures of the Pelvis, and Traumatic Separations at its Sym- 
physes. 350 

I 1. Pubes, 350 

I 2. Ischium, 354 

I 3. Ilium, 355 

\ 4. Acetabulum, 359 

\ 5. Sacrum, 365 

I 6. Coccyx, 3G7 

CHAPTER XXVIII. 

Fractures of the Femur, 307 

I 1. Neck of the Femur, 368 

(a.) Neck of the Femur within the Capsule, 369 

(b.) Neck of the Femur without the Capsule, 393 

(c.) Neck of the Femur partly within and partly without the 

Capsule, 401 

\ 2. Fractures through the Trochanter Major and Base of the Neck of the 

Femur, 401 

\ 3. Fractures of the Epiphysis of the Trochanter Major, .... 403 

I 4. Fractures of the Shaft of the Femur, 404 

I 5. Fractures of the Condyles, 455 

(a.) Fractures of the External Condyle, 455 

(b.) Fractures of the Internal Condyle, ...... 456 

(c.) Fractures between the Condyles and across the Base, . . 458 

{d.) Separation of the Lower Epiphysis, 460 

CHAPTER XXIX. 

Fractures of the Patella, 461 

CHAPTER XXX. 

Fractures of the Tibia, 472 

CHAPTER XXXI. 

Fractures of the Fibula, 477 

CHAPTER XXXII. 

Fractures of the Tibia and Fibula, 481 

CHAPTER XXXIII. 

Fractures of the Tarsal Bones, . 502 

CHAPTER XXXIV. 

Fractures of the Metatarsal Bones, 507 



CONTENTS. XI 

CHAPTER XXXV. 

PAGE 

Fractures of the Phalanges of the Toes, 509 

CHAPTER XXXVI. 
Gunshot Fractures, .510 



PAET II. 

DISLOCATIONS. 

CHAPTER I. 

General Considerations, 525 

g 1. Division and Nomenclature, 525 

$ 2. Predisposing Causes, 526 

\ 3. Direct or Exciting Causes, 527 

I 4. Symptoms, 527 

§ 5. Pathology, . 528 

I 6. Prognosis, 530 

\ 7. Treatment, 530 

CHAPTER II. 

Dislocations of the Lower Jaw, 533 

\ 1. Double or Bilateral Dislocations, 533 

\ 2 Single or Unilateral Dislocations, . . . . . . . . 537 

\ 3. Conditions of the Jaw simulating Luxations, ..... 538 



CHAPTER III. 



540 
541 
542 
545 
551 



Dislocations of the Spine, 

$ 1. Dislocations of the Lumbar Vertebrae, 
§ 2. Dislocations of the Dorsal Vertebras, . 
\ 3. Dislocations of the Six Lower Cervical Vertebras, 
§ 4. Dislocations of the Atlas, .... 

\ 5. Dislocations of the Head upon the Atlas, or Occipito-Atloidean Dis- 
locations, ............ 553 

CHAPTER IV. 

Dislocations of the Ribs, 553 

\ 1. Dislocations of the Ribs from the Vertebras, ..... 553 

\ 2. Dislocations of the Ribs from the Sternum, ..... 555 

\ 3. Dislocations of one Cartilage upon another, 556 



Xll CONTENTS. 



CHAPTER V. 

PAGE 

Dislocations of the Clavicle, 557 

$ 1. Sterno-Clavicular, 557 

(a.) Dislocations Forwards at the Sternal End, .... 557 

(b.) Dislocations of the Sternal End of the Clavicle Upwards, . 561 

(c.) Dislocations of the Sternal End of the Clavicle Backwards, . 562 

§ 2. Acromioclavicular, 564 

(a.) Dislocations of the Acromial End of the Clavicle Upwards, . 564 

(&.) Dislocations of the Acromial End of the Clavicle Downwards, 570 
(c.) Dislocations of the Acromial End of the Clavicle under the 

Coracoid Process, . . . . . . . •. . 571 

(d.) Dislocations of the Clavicle at both ends simultaneously, . 572 

CHAPTER VI. 

Dislocations or the Shoulder (Scapulo-Humeral), .... 573 
\ 1. Dislocations of the Shoulder Downwards (Subglenoid), . . . 574 
Dislocations, with Fracture of the Humerus near its Upper End, . 601 
$ 2. Dislocations of the Humerus Forwards (Subcoracoid and Subclavic- 
ular), 602 

I 3. Dislocations of the Humerus Backwards (Subspinous), . . . 609 

3 4. Partial Dislocations of the Humerus, 613 



CHAPTER VII. 

Dislocations or the Head of the Radius (Humero-Radial), 
\ 1. Dislocations of the Head of the Radius Forwards, . 
§ 2. Dislocations of the Head of the Radius Backwards, . 
§ 3. Dislocations of the Head of the Radius Outwards, . 

CHAPTER VIII. 



617 
617 
622 
624 



Dislocations of the Upper End of the Ulna Backwards (Humero- 

Ulnar), 625 

CHAPTER IX. 

Dislocations of the Radius and Ulna (Forearm at the Elbow-Joint), 626 

| 1. Dislocations of the Radius and Ulna Backwards, .... 626 

$ 2. Dislocations of the Radius and Ulna Outwards (to the Radial Side), 636 

\ 3. Dislocations of the Radius and Ulna Inwards (to the Ulnar Side), . 641 

$ 4. Dislocations of the Radius and Ulna Forwards, .... 644 



CHAPTER X. 






Dislocations of the Wrist (Radio-Carpal) , 645 

\ 1. Dislocations of the Carpal Bones Backwards, ..... 648 

$ 2. Dislocations of the Carpal Bones Forwards, ..... 651 

CHAPTER XI. 

Dislocations of the Lower End of the Ulna (Inferior Radio-Ulnar), 652 

$ 1. Dislocations of the Lower End of the Ulna Backwards, . . . 652 

§ 2. Dislocations of the Lower End of the Ulna Forwards, . . . 654 



CONTENTS. Xlll 



CHAPTER XII. 

PAGE 

Dislocations of the Carpal Bones (among themselves), . . . 655 

CHAPTER XIII. 

Dislocations of the metacarpal Bones (at the Carpo-Metacarpal 

Articulations), . 657 

CHAPTER XIV. 

Dislocations of the First Phalanges of the Thumb and Fingers 

(Metacarpophalangeal), . . . . . . . 660 

\ 1. Dislocations of the First Phalanx of the Thumb Backwards, . . 660 
\ 2. Dislocations of the First Phalanx of the Thumb Forwards, . . 667 
I 3. Dislocations of the First Phalanx of the Fingers, . . . .668 

CHAPTER XV. 

Dislocations of the Second and Third Phalanges of the Thumb 

and Fingers (Phalangeal),. 669 

CHAPTER XVI. 

Dislocations of the Thigh (Coxo-Femoral), 672 

\ 1. Dislocations Upwards and Backwards on the Dorsum Ilii, . . 674 
§ 2. Dislocations Upwards and Backwards into the Great Ischiatic 

Notch, 701 

\ 3. Dislocations Downwards and Forwards into the Foramen Thy- 

roideum, ............ 709 

$ 4. Dislocations Upwards and Forwards upon the Pubes, . . . 714 
$ 5. Anomalous Dislocations, or Dislocations which do not properly belong 

to either of the four principal divisions before described, . 719 

1. Dislocations directly Upwards, 719 

2. Dislocations Downwards and Backwards upon the Posterior 

Part of the Body of the Ischium, between its Tuberosity 

and its Spine, 723 

3. Dislocations Downwards and Backwards into the Lesser or 

Lower Ischiatic Notch, ....... 723 

4. Dislocations direct^ Downwards, ...... 724 

5. Dislocations Forwards into the Perineum, . . . . 725 

| 6. Ancient Dislocations of the Femur, 727 

| 7. Partial Dislocations of the Femur, 731 

\ 8 Coxo-Femoral Dislocations, complicated with Fracture of the Femur, 732 

I 9. Voluntary Dislocations of the Femur, 735 

CHAPTER XVII. 

Dislocations of the Patella, .... 
§ 1. Dislocations of the Patella Outwards, 
§ 2. Dislocations of the Patella Inwards, . 
§ 3. Dislocations of the Patella upon its Axis, 
\ 4. Dislocations of the Patella Upwards, 



737 
737 
740 
740 
744 



XIV 



CON TENTS. 



CHAPTER XVIII. 

Dislocations of the Head of the Tibia (Femoro-Tibial) 
g 1. Dislocations of the Head of the Tibia Backwards, 
\ 2. Dislocations of the Head of the Tibia Forwards, 
\ 3. Dislocations of the Head of the Tibia Outwards, 
\ 4. Dislocations Of the Head of the Tibia Inwards, . 
§ 5. Dislocations of the Head of the Tibia Backwards and Outwards 
% 6. Internal Derangement of the Knee-Joint, . 



PAGE 

745 

746 
748 
750 
752 
752 
754 



CHAPTER XIX. 

Dislocations or the Lower End of the Tibia (Tibio-Tarsal) 
\ 1. Dislocations of the Lower End of the Tibia Inwards, 
\ 2. Dislocations of the Lower End of the Tibia Outwards, 
\ 3. Dislocations of the Lower End of the Tibia Forwards, 
\ 4. Dislocations of the Lower End of the Tibia Backwards, . 



756 
756 
761 
762 

766 



CHAPTER XX. 

Dislocations of the Upper End of the Fibula, . 

\ 1. Dislocations of the Upper End of the Fibula Forwards, 
\ 2. Dislocations of the Upper End of the Fibula Backwards, 



767 
767 
768 



CHAPTER XXL 

Dislocations of the Inferior Peroneo-Tibial Articulation, 



"69 



CHAPTER XXII. 



Tarsal Luxations, 

§ 1. Dislocations of the Astragalus, . 

Astragal o-Calcaneo-Scaphoid Dislocations, 
Dislocations of the Calcaneum, . 
Middle Tarsal Dislocations, 
Dislocations of the Os Cuboides, 
Dislocations of the Os Scaphoides, 
Dislocations of the Cuneiform Bones, . 



2 2. 

2 3. 

M. 

2 5. 
2 6. 

2 7. 



769 
769 

777 
778 
779 
779 
780 
780 



CHAPTER XXIII. 

Dislocations of the Metatarsal Bones, . 



782 



CHAPTER XXIV. 

Dislocations of the Phalanges of the Toes, 



784 



CHAPTER XXV. 

Compound Dislocations of the Long Bones, 



785 



CONTENTS. 



XV 



CHAPTER XXVI. 



Congenital Dislocations, . 

\ 1. General Observations and History, 
Etiology,' 



Congen 
Congen 
Congen 
Congen 
Congen 
Congen 
rus), 
Congen 
Congen 

11. Congen 

12. Congen 

13. Congen 

14. Congen 

15. Congen 

16. Congen 

17. Congen 



10 



tal Dislocations of the Inferior Maxilla, 

tal Dislocations of the Spine, .... 

tal Dislocations of the Pelvic Bones, 

tal Dislocations of the Sternum, . 

tal Dislocations of the Clavicle, 

tal Dislocations of the Shoulder (Upper End of 



the Hume- 



tal Dislocations of the Radius and Ulna Backwards, 

tal Dislocations of the Head of the Radius 

tal Dislocations of the Wrist, 

tal Dislocations of the Fingers, 

tal Dislocations of the Hip, . 

tal Dislocations of the Patella, 

tal Dislocations of the Knee, . 

tal Dislocations of the Tarsal Bones, 

tal Dislocations of the Toes, . 



PAGE 

801 
801 
802 
804 
807 
808 
808 
808 

809 
812 
813 
814 
814 
815 
821 
822 
824 
824 



LIST OF ILLUSTRATIONS. 



FIG. 
1. 

2. 
3. 
4. 

5. 

6. 



9. 
10 
11. 

12. 
13. 
14. 
15. 
16. 
17. 

18. 
19. 
20. 
21. 
22. 
23. 
24. 
25. 

26. 
27. 
28. 
29. 
30. 
31. 
32. 
33. 



FRACTURES. 

Transverse, serrated (denticulated), and oblique fracture. From author's 

collection, ........... 

Perforating and longitudinal fracture, . . . . . 

Impacted extra-capsular fracture of neck of femur — vertical section, 
Fracture of the thigh of a turkey united with fragments widely sepa 

rated. From a specimen in the author's cabinet, .... 
Fracture of the shaft of the femur ; united with an oblique callus. From 

a specimen in the author's cabinet, ..... 

Application of the " roller," by circular and reversed turns, 
Many-tailed bandage, ........ 

Application of the many-tailed bandage, .... 

Bandage of Scultetus, ........ 

Wood and leather splint, ....... 

Starch bandage applied for a broken thigh, 

Seutin's pliers, ......... 

Opening of the apparatus with Seutin's pliers, . 

" Apparatus immobile," applied over a compound fracture, 

Von Brun's plaster-cutter, ....... 

Clavicle, united by ligamentous bands, .... 

Hudson's splint for ununited fractures of femur, accompanied with short 

ening of the limb, ........ 

Physick's first case, after 28 years, . . . . 

Dieffenbach's drill for ununited fracture, .... 

Brainard's perforator reduced one-half, .... 

The author's bone-drill, 

Gaillard's instrument for ununited fractures, 
Fergusson's case of permanent bending without fracture, . 
Partial fracture without restoration of the bone to its natural form 



Partial fracture of the clavicle without spontaneous 

nature ; taken three weeks after the accident 
Partial fracture after union is consummated, 
Fracture of the lower jaw, . 
Bean's maxillary articulator, 
Bean's apparatus for broken jaw, applied 
Plaster model of jaws, 
Kingsley's apparatus reversed, . • . 
Same applied to model, 
Gibson's bandage for a fractured jaw, . 

2 



restoration. 



From 



28 
28 
28 

41 

41 
46 
46 
47 
47 
51 
54 
55 
57 
58 
61 
65 

69 
69 
70 
71 

72 
73 

77 
82 

82 
84 
111 
127 
128 
131 
131 
132 
132 



XV111 



LIST OF ILLUSTRATIONS. 



nd of 



FIG. 

84. Barton's bandage for a fractured jaw, 

85 Four-tailed bandage or sling for the lower jaw, . 

86. The author's apparatus for a broken jaw, . 

37. Fracture of the spinous process, 

38. Fracture of the vertebral arch, 

39. Oblique fracture of the body of a vertebra, . 

40. Key's ease of fracture of the first lumbar vertebra, . 

41. Wire bed, 

42. Parker's case of fracture of the odontoid process of the ax 

43. Development of sternum, 

44. Fracture of the ribs, with lateral union, . 

45. Complete oblique fracture of the clavicle, ... 

46. Fracture of the clavicle outside of the trapezoid ligament 

47. Complete oblique fracture of the clavicle at the outer e 

two-thirds, ........ 

48. Comminuted fracture of the clavicle united, 

49. Velpeau's dextrin bandage ; no axillary pad, 

50. Figure-of-8 bandage, for a fractured clavicle, . 

51. Moore's apparatus for fractured clavicle. Back view, 

52. Moore's apparatus for fractured clavicle. Front view, 

53. Sayre's apparatus for fractured clavicle, 

54. Sayre's apparatus for fractured clavicle, 

55. Sayre's apparatus for fractured clavicle, 

56. Bartlett's apparatus for fractured clavicle, 

57. Fox's apparatus for fractured clavicle, 

58. The author's apparatus for fractured clavicle, 

59. Fracture of angle of the scapula, .... 

60. Fractures of the body and acromion process of the scapula 

61. Comminuted fracture of the glenoid cavity, 

62. Fracture of the neck of the scapula, .... 

63. Scapula with epiphyses, ...... 

64. Fracture of the coracoid process, .... 

65. Fracture at the anatomical neck of the humerus, 

66. Pope's specimen of supposed fracture at the anatomical necl 

and reversion of the head, 

67. Same, 

68. Humerus with epiphyses, . 

69. Upper epiphysis of humerus, 

70. Epiphyseal separation, 

71. Fracture of surgical neck of humerus, 
72 Plan of author's long leather arm splint, 

73. Long leather splint closed at top and in shape, 

74. Short splint, 

75. Lonsdale's apparatus for extension, in fractures of the humerus 

76. Martin's extension in fractures of the humerus,. 

77. Clark's extension in fractures of the humerus, . 

78. Fracture of the humerus at the base of the condyles 

79. Separation of lower epiphyses, . . . 

80. Keeve's case of separation of the lower epiphysis of the humerus 

81. Rose's arm and forearm splint, . 

82. Welch's arm and forearm splint, 

83. Bond's elbow splint, .... 



ofth 



the 



e humerus 



LIST OF ILLUSTRATIONS. 



XIX 



us, 



FIG. 

84. The author's elbow splint, ........ 

85. Fracture at the base of the condyles of the humerus, and between the con 

dyles, 

86. Fracture of internal epicondyle of the humerus, 
87 Fracture of external epicondyle, .... 

88. Fracture of the internal condyle of the humerus, 

89. Fracture of external condyle, 

90. Mutter's specimen of fracture of the neck of the radius, 

91. Fracture of head of radius, 

92. Scott's apparatus for fractures of the forearm, 

93. Fracture of the shaft of the radius, .... 

94. Colles's fracture — radius near its lower end, 

95. Impacted fracture. Author's collection, . 

96. Comminuted fracture. Author's collection, 

97. Bigelow's case of comminuted fracture of the lower end of the rad 

98. Nelaton's splint for fracture of the radius near its lower end, 

99. Bond's splint for fracture of the lower end of the radius, 

100. Hay's splint for fracture of the lower end of the radius, . 

101. E. P. Smith's splint for fracture of the lower end of the radius — front 

view, ...... 

102. Same as above — back view, 

103. Shrady's splint for Colles's fracture, . 

104. Hewit's splint, 

105. Author's palmar splint ; right arm, . 

106. Author's dorsal splint, 

107. The author's dressing for a fracture of the : 

complete, ...... 

108. Radius, with epiphyses, .... 

109. Fracture of the shaft of the ulna, 

110. Fracture of the coronoid process of the ulna 

111. Ulna, with epiphyses, .... 

112. Fracture of the olecranon process at its base, 
113 Olecranon process united by ligament, 

114. Sir Astley Cooper's method of dressing a fracture of theol 

115. The author's splint for a fracture of the olecranon proce 

116. Fracture of the radius and ulna in the middle third, 

117. Fracture of the radius and ulna in the lower third, 

118. Radius and ulna united with displacement, 

119. Palmar splint, ........ 

120. Gutta-percha splint for finger, ..... 

121. Development of os innominatum, .... 

122. Clark's case of comminuted fracture of the pelvis, . 

123. Development of femur, ...... 

124. Fracture of the neck of the femur, within the capsule, 

125. Intracapsular fracture caused by a fall upon the trochanter, . 

126. Impacted fracture of the neck of the femur, within the capsule, 

127. Horizontal section of the neck of the femur, .... 

128. Extracapsular fracture with inversion, ..... 

129. Vertical section of Mrs. Wakelee's femur, acetabulum, and capsule 

130. Impacted fracture within the capsule, .... 

131. Section of the head and neck of the sound femur of an adult 

132. Chronic rheumatic arthritis, in hip-joint, 



adi 



its lower 



end- 



ecranon process, 
s, applied, 



PAGE 

264 

265 
268 
272 
273 
276 
280 
282 
284 
285 
287 
291 
291 
291 
298 
298 
298 

299 
299 
299 
300 
304 
304 

305 
310 
311 
316 
319 
325 
327 
329 
330 
332 
333 
333 
342 
349 
351 
352 
368 
370 
372 
373 
377 
377 
383 
384 
385 
386 



XX 



LIST OF ILLUSTRATIONS. 



Fit;. 
133. 

134. 

135. 
136. 
137. 
138. 
139. 
140. 
141. 
142. 
143. 
144. 

145. 
146. 
147. 
148. 
149. 
150. 
151'. 
152. 
153. 
154. 
155. 
156. 
157. 
158. 
159. 
160. 
161. 
162. 



Crosby's specimen of fracture of neck of femur within the capsule— un- 
united, ............. 

Mayo's specimen of fracture of the neck of the femur within the capsule 
— united by ligament, 

Autbor's apparatus for fractures of the neck of the femur, 

Gibson's modification of Hagedorn's thigh splints, . 

Gibson's modified splint applied, 

Impacted extracapsular fracture, 



Same, ..... 

Same, 

Fracture of the neck of the femur 

Extracapsular fracture of the neck of the femur — ununited, 

Extracapsular fracture of the neck of the femur— with excess 



major, 



nt, 



Extracapsular fracture of the neck of the femur— united with irregular 

callus, ........ 

Miller's splint for extracapsular fractures, 
Mr. Aston Key's case, ..... 

Sir Astley Cooper's mode of treating fractures of the trochanter 
Fracture of the femur at the base of the condyles, 

Physick's thigh splint, 

Liston's dressing of fractured femur with a straight splii 

Double-inclined plane in Middlesex Hospital, London, 

Amesbury's double-inclined plane, . 

Amesbury's splint applied, .... 

Boyer's thigh splint applied, .... 

Nathan R. Smith's suspending apparatus, or double- 

Nott's double-inclined plane, .... 

N. R. Smith's anterior splint, .... 

N. R. Smith's anterior splint, applied, 

Palmer's modification of the anterior splint, . 

Hodgen's suspension apparatus, 

Weill's straight thigh splint, for extension and counter-e: 

Flagg's thigh apparatus — employed in the Massachusetts General 

pital. Pelvic belt and perineal straps, . 
Same — foot-piece and screw, .... 



incl 



ned pi 



163 

164. Same — lateral view of the apparatus, without the belt, 

165. Same — front view, with folded sheets laid across, . 

166. Same — apparatus applied, front view, 

167. Same — apparatus applied, side view, 

168. Same — mode of applying adhesive plasters to leg, . 

169. Same — mode of making extension by adhesive plasters, 

170. Same — perineal band secured with a padlock, 

171. Gurdon Buck's fracture apparatus, . 

172. Horner's thigh splint, .... 

173. Joseph Hartshorne's thigh splint, 

174. Gilbert's extension in fracture of the thigh, 

175. Gilbert's extension applied to both thighs, 

176. H. L. Hodge's counter-extension in fracture of 

177. Lente's thigh splint, .... 

178. Burge's apparatus for fracture of femur, 

179. Burge's apparatus applied, 

180. Dr. Gibbes's case, posterior view, 



the femu 



of 



callus, 



tension. 



Hos- 



PAGE 

389 



LIST OF ILLUSTRATIONS. 



XXI 



FIG. PAGE 

181. Dr. Gibbes's case, anterior view, 438 

182. Extension during application of plaster of Paris, ..... 441 

183. Extension continued until the plaster is hard, 441 

184. Fracture of femur just below trochanter minor, ..... 442 

185. Jenks's fracture-bed, 445 

186. Daniels's fracture-bed — descriptive diagram, ...... 446 

187. The same — complete, 447 

188. The same — in use, 447 

189. Crosby's invalid-bed, closed, 448 

190. Crosby's invalid-bed, open, ......... 449 

191. Standard for extension, . . . . 449 

192. Foot-piece, ' 450 

193. Extension-band and foot-piece, . . . . . . . . . 450 

194. Extension-band and foot-piece folded, 450 

195. Mode of applying adhesive plaster for extension, ..... 452 

196. Author's dressing for fracture of shaft of femur, complete, . . . 453 

197. Author's splint for fracture of femur in a child, 454 

198. Author's dressing for fracture of femur in a child — complete, . . 454 

199. Crosby's specimen of fracture of the external condyle of the femur, . 455 

200. Sir Astley 's Cooper's case of fracture of the external condyle of the femur, 456 

201. Transverse fracture of the patella, ........ 462 

202. Comminuted fracture of the patella, .... .... 462 

203. Transverse fracture of the patella — exhibiting the relations of the mus- 

cles to the fracture, .......... 462 

204. Fragments of a broken patella separated by flexion of the knee, . . 462 

205. Upper fragment of a broken patella drawn up very much by the action 

of the quadriceps femoris, 463 

206. The author's mode of dressing a fractured patella, 466 

207. Wood's apparatus for a fractured patella, ....... 467 

208. Dorsey's patella splint, 468 

209. Sir Astley Cooper's method for broken patella by circular and parallel 

tapes, 468 

210. Sir Astley Cooper's method by a leather band and counter-strap, . . 469 

211. Lonsdale's apparatus for fractured patella, 469 

212. Beach's apparatus, ........... 470' 

213. Beach's apparatus applied, 471 

214. Malgaigne's hooks for fractured patella, 471 

215. Burge's apparatus for fractured patella, ....... 471 

216. Lausdale's apparatus for fractured patella, ...... 472 

217. Development of tibia, 473 

218. Development of fibula, 477 

219. Fracture of the fibula near its lower end, 478 

220. Dupuytren's splint incorrectly applied, 480 

221. Dupuytren's splint, as originally made and applied by himself, . . 480 

222. Compound and comminuted fracture of the leg, ..... 483 

223. Plaster of Paris dressing for fracture of leg, and suspension, . . . 491 

224. Yan "Wagener's suspension apparatus, 492 

225. Hutchinson's splint for extension in fractures of the leg, . . . . 493 

226. Neill's apparatus for fractures of the leg requiring extension and counter- 

extension, 494 

227. Neill's apparatus for compound fractures of the leg, .... 494 

228. Gilbert's fracture-box, 495 



XX 11 



LIST OF ILLUSTRATIONS. 



compound 



FIG. 

229. Crandall's apparatus for fractures of the leg requiring extension and 

counter-extension — side view, 

230. Same — posterior view of the entire apparatus, 

231. Same — posterior view of the lower section, 

232. Liston's double-inclined plane, applied to the leg in a case of 

fracture, 

233. Bauer's wire splints for the leg, 

234. Swing box for fractures of the leg, . 

235. Salter's cradle for fractures of the leg, 

236. Fracture-box for the leg, with movable sides, 

237. Wire rack for fracture of the leg, 

238. Malgaigne's apparatus for certain oblique fractures of the leg, 

239. Malgaigne's apparatus applied, 

240. Apparatus for fracture of the tuberosity of the calcaneum, 

241. Author's movable canvas for gunshot fractures of thigh, 

242. Author's movable canvas for gunshot fractures of thigh, with 

on horses, 

243. Hodgen's apparatus for gunshot fractures of the thigh, 

244. Same, 

245. Gunshot fracture of thigh — front view, 

246. Same — side view, 



extension, 



495 
496 
496 

497 
498 
498 
499 
499 
500 
500 
501 
507 
514 

514 
515 
515 
521 
521 



DISLOCATIONS. 



la, 



247. Clove-hitch, 

248. Compound pulleys and ring, 

249. Double dislocation of the inferior maxi 

250. Same, 

251. Ayres's case of bilateral dislocation of the fifth cervical vertebra, 

252. Dislocation of the sternal end of the clavicle forwards, . 

253. Sir Astley Cooper's apparatus for dislocated clavicle, 
254 Dislocation of sternal end of clavicle upwards, 

255. Dislocation of the acromial end of the clavicle upwards, . 

256. Dislocation of acromial end of clavicle upwards and outwards, 

257. Mayor's apparatus for dislocated clavicle, .... 

258. Dislocation of the shoulder downwards into the axilla, . 

259. Same, 

260. New socket in an ancient luxation of the shoulder downwards, 

261. N. R. Smith's method of reducing a dislocation of the shoulder, 

262. La Mothe's method of reducing a dislocation of the shoulder — modi 

263. Sir Astley Cooper's method, with the heel in the axilla, . 

264. Sir Astley Cooper's method, with the knee in the axilla, 

265. Iron knob employed by Skey instead of the heel 

266. Skey's method in dislocations of the shoulder, 

267. Sir Astley Cooper's method by means of pullej 

268. Subcoracoid dislocation of the humerus, . 

269. Subclavicular dislocation of the humerus, 

270. Subcoracoid dislocation of the humerus, 



i tied. 



582 
532 
535 
536 
551 
558 
560 
562 
566 
566 
569 
575 
576 
583 
588 
589 
589 
590 
591 
591 
592 
604 
604 
605 



LIST OF ILLUSTRATIONS. XX111 

FIG. PAGE 

271. Subspinous dislocation of the humerus, 611 

272. Displacement of the long head of the biceps, 615 

273. Dislocation of the head of the radius forwards — anatomical relations, . 618 

274. Dislocation of the head of the radius forwards, 618 

275. Dislocation of the head of the radius backwards, 624 

276. Dislocation of the upper end of the ulna backwards, .... 626 

277. Dislocation of the radius and ulna backwards, 627 

278. Sir Astley Cooper's method in dislocation of the radius and ulna back- 

wards, ............. 631 

279. Most frequent form of incomplete outward dislocation of the forearm, . 637 

280. Most frequent form of incomplete inward dislocation of the forearm, . 642 

281. Canton's case— dislocation of the radius and ulna forwards, . . . 644 

282. Dislocation of the carpal bones backwards, 649 

283. Same, 650 

284. Dislocation of the carpal bones forwards — skeleton, .... 651 

285. Dislocation of the carpal bones forwards, 652 

286. Dislocation of the first phalanx of the thumb backwards, . . . 660 

287. Clove-hitch, 662 

288. Sir Astley Cooper's method of reducing dislocations of the thumb by the 

pulleys, 663 

289. Levis's instrument for reduction of the phalanges, 665 

290. Same, 666 

291. Indian "puzzle" — employed in the reduction of dislocations of small 

joints, 666 

292. Backward dislocation of the first phalanx of the index finger — reduction 

by extension, ........... 669 

293. Dislocation of the second phalanx backwards, ...... 670 

294. Dislocation of the second phalanx forwards, ...... 671 

295. Dislocation of the femur upon the dorsum ilii, ..... 675 

296. Ilio-femoral ligament, .......... 677 

297. Dislocation of the femur upon the dorsum ilii, showing relations of ilio- 

femoral ligament, 678 

298. Dislocation of the femur upon the dorsum ilii, ..... 679 

299. Everted dorsal dislocation, 680 

300. Nathan Smith's method of reduction of a dislocation of the head of the 

femur upon the dorsum ilii, by manipulation, 685 

301. Eelaxation of the ilio-femoral ligament, by flexion, .... 687 

302. Hippocrates's mode of reducing dislocations of the hip by extension, 688 

303. Reduction of a dislocation upon the dorsum ilii by pulleys, . . . 689 

304. Reduction of a dislocation upon the dorsum ilii by the Spanish wind- 

lass, 690 

305. Jarvis's adjuster — applied in dislocation of the hip, .... 691 

306. Bloxhanvs dislocation tourniquet — applied for reduction of a dislocation 

of the femur upon the pubes, ........ 691 

307. Bigelow's tripod for vertical extension, ....... 700 

308. Dislocation of the femur upwards and backwards into the great ischi- 

atic notch, 702 

309. Same, 702 

310. Internal obturator in its natural position, 703 

311. Internal obturator in its new position, 703 

312. Dislocation upwards and backwards into the great ischiatic notch — 

"below the tendon," when the patient is recumbent, .... 704 



XXIV LIST OF ILLUSTRATIONS. 

FIG. PAGE 

313. Reduction of a dislocation into the great ischiatic notch, by pulleys, . 707 

314. Relations of the ilio-femoral ligament to thyroid dislocations, . . 710 

315. Dislocation of the femur downwards and forwards into the foramen 

thyroideum, 710 

310. Reduction of thyroid dislocation by manipulation, .... 711 

317. Sir Astley Cooper's mode of reducing recent luxations of the femur into 

the foramen thyroideum, 713 

318. Effect of flexion upon the ilio-femoral ligament in the thyroid disloca- 

tion 714 

319. Specimen of dislocation upon the pubes, in St. Thomas's Hospital, . 715 

320. Dislocation upon the pubes below the anterior inferior spine of the 

ilium, 716 

321. Dislocation upwards and forwards upon the pubes, .... 717 

322. Reduction of dislocation upon the pubes by extension, .... 719 

323. Anterior oblique dislocation, 721 

324. Mechanism of anterior oblique dislocation, 721 

325. Supraspinous dislocation, 722 

326. Voluntary subluxation upon the dorsum ilii, 736 

327. Same, 736 

328. Dislocation of the patella outwards, 738 

329. Dislocation of the patella inwards, ........ 740 

330. Dislocation of the head of the tibia backwards, 746 

331. Incomplete dislocation of the head of the tibia forwards, . . . 748 

332. Subluxation of the head of the tibia outwards, ..... 751 

333. Subluxation of the head of the tibia inwards, ..... 752 

334. Dislocation of the lower end of the tibia inwards, .... 757 

335. Same, 758 

336. Reduction of a dislocation of the ankle by pulleys, .... 759 

337. Dislocation of lower end of the tibia outwards, . . . . 761 

338. Partial dislocation of the tibia forwards, with fractures of malleolus 

internus and fibula — skeleton, ........ 763 

339. Partial dislocation of the tibia forwards, with fracture of the malleolus 

internus and fibula, . . . . . . . . . 763 

340. Dislocation of the lower end of the tibia backwards, .... 766 

341. Same, 766 

342. Dislocation of the astragalus outwards — anatomical relations, . . 770 

343. Simple dislocation of the astragalus outwards, . . . . 771 

344. Compound dislocation of the astragalus inwards, 771 



PART I. 



FRACTURES. 



FRACTURES. 



CHAPTEE I. 

GENERAL DIVISION OF FRACTURES. 

Fractures are divided into Complete and Incomplete, Simple, 
Comminuted, Compound, and Complicated. 

A Complete fracture is one in which the line of division completely 
traverses the bone. 

An Incomplete fracture is a partial separation of the bone : under 
which name are included Bending, Partial fractures, Fissures and 
Punctured or Perforating fractures, the last of which is almost peculiar 
to gunshot injuries. 

A Simple fracture is one in which the bone is broken at only one 
point. The term has no reference to the question of complications, but 
in its technical meaning, as employed by both English and American 
surgeons, it has reference only to the number of fragments into which 
the bone is broken. It would be more correct, perhaps, to substitute 
the word " single" for " simple," as has been done by Malgaigne and 
some other French writers, but I fear that to American surgeons the 
substitution would be rather a source of confusion than otherwise. 

A Comminuted fracture, called by Malgaigne "multiple," is a frac- 
ture in which the bone is broken at more than one point, and in which, 
consequently, the bone is divided into more than tw T o fragments. It 
is used also in a technical sense, and by no means implies minute 
division or comminution of the fragments. 

A Compound fracture is technically one in which there exists also 
an external wound communicating with the bone at the point of frac- 
ture. It may be either partial or complete, simple or comminuted, or 
even complicated, w r hile at the same time it is also compound. 

Complicated fractures are such as present additional complications, 
or complications for which no other specific term has been invented. 
Thus, the fracture may be complicated with the lesion of an important 
bloodvessel or nerve, or with great contusion or laceration of the soft 
parts, with a dislocation, or with fractures of other bones, or even with 
some constitutional fault. 

Fractures are also divided into Transverse, Oblique, and Longitu- 
dinal, according as the direction of the line of separation is at a right 



28 



GENERAL DIVISION OF FRACTURES. 



Fig. 1. 






angle with the axis of the bone at the point of fracture, or as it deviates 
more or less from this direction. But a fracture is called transverse 

when it does not traverse the bone precisely 
at a right angle ; indeed, we usually apply 
this term whenever the obliquity is only 
moderate, or when, in the examination of 
a limb, although we are unable to detect 
the precise line of the fracture, we ascer- 
tain that, without being impacted or ser- 
rated, the ends of the bones continue to 
rest upon each other, or, being replaced, 
do not spontaneously become displaced. 

Longitudinal fractures occur generally 
in connection with oblique or transverse 
fractures; as when the lower end of the 
femur is split vertically into the joint, and 
the shaft of the bone is traversed horizon- 
tally by a fracture which intercepts the ver- 
tical or longitudinal fracture. A fracture 
of a condyle, or of any projection from the 
body of the bone, is called longitudinal if the 
direction of the line of fracture is parallel, 
or nearly so, to the axis of the shaft. 

A Serrated fracture is one in which the 
opposite surfaces denticulate, the eleva- 
tions upon one fragment being reflected 
by corresponding depressions upon the 
other. 
Impacted fractures are those in which the fragments are driven into 



Transverse, ser- 
rated (denticu- 
lated) fracture 



Oblique fracture. 
From author's 
collection. 



Fig. 2. 



Fig. 3. 





Perforating and longitudinal fracture. 



Impacted, extra-capsular fracture of 
neck of femur.— Vertical section. 



each other, the lamellated structure of one fragment penetrating the 
cancellous structure of the other. 



GENERAL ETIOLOGY OF FRACTURES. 29 

Writers also occasionally speak of fractures en rave, en bee de flute, 
en bee de plume, spiroid, cuneate, etc. ; but we do not see the propriety 
of multiplying the divisions and incumbering our nomenclature by 
these fancied resemblances. For all useful purposes, the divisions 
above given are sufficient. 

Epiphyseal separations we shall not hesitate to class with fractures, 
and to submit them to the same rules of nomenclature. These acci- 
dents rarely occur after the twentieth year of life ; since after this 
period, and in the case of some bones at a much earlier period, the 
epiphyses are usually united to the diaphyses by bone. 



CHAPTER II. 

GENERAL ETIOLOGY OF FRACTURES. 

The causes of fracture may be considered as predisposing and ex- 
citing. 

Predisposing Causes.— -Partial fractures, with bending of the bones, 
are most frequent in infancy and childhood; but complete fractures 
occur most often during manhood ; and if they are again less frequent 
in old age, it is because the exciting causes are less operative, since the 
fragility of the bones, as a general rule, increases with age. It will be 
noticed, also, that somewhat in proportion as the bone is more brittle, 
its fracture will be more nearly transverse, so that very old persons 
have frequently what has been not inaptly termed the " pipe-stem frac- 
ture;" but we must except from this rule fractures occurring in chil- 
dren, which are also not unfrequently transverse, often denticulated or 
splintered, and but rarely oblique. In all of the intermediate periods 
of life, oblique fractures are by far the most common. Females are 
less liable to fractures than males, except in old age, when the law 
seems, in general, to be reversed. As to the season of the year, it has 
been generally observed by surgical writers that fractures were more 
frequent in winter than in summer, and an explanation has been 
sought for in the greater rigidity of the muscles during the cold weather, 
and the greater liability to falls upon the ice and frozen ground. Some 
have affirmed that the bones themselves were more brittle; but, aside 
from the improbability of this last explanation, it is a matter of ques- 
tion whether fractures are actually more frequent in the winter than 
in the summer. If, on the one hand, the rigidity of the muscles and 
falls upon slippery walks are active causes in the production of frac- 
tures in the one season, on the other hand, falls from buildings and ac- 
cidents from a great variety of similar causes are equally active agents 
in the other. 

Mollities ossium, rickets, cancer, tertiary lues, scrofula, gout, scurvy, 
mercurialization, and, in short, all diseases dependent upon cachexia, 
more or less predispose to the occurrence of fractures. Inflammation 



30 GENERAL ETIOLOGY OF FRACTURES. 

of the periosteum, also, or of the bone itself, may predispose to fracture. 
It is said, moreover, that the bones of persons who have lain a long 
time in bed break easily. 

Exciting Causes. — The exciting, determining, or immediate causes 
of fractures are of two kinds : mechanical violence and muscular ac- 
tion. 

Of these two, mechanical or external violence is much the most fre- 
quent cause ; and this violence may operate in two ways : by acting 
directly upon the bone at the point at which it separates, and then we 
say the fracture is "direct," or from "direct violence;" or by acting 
upon some point remote from the seat of fracture, and then we say the 
fracture is "indirect," or from a "counter-stroke." When a person 
falls from a height, alighting upon his feet, and the leg or thigh is 
broken, the fracture is indirect; so also if the bone is broken by flexion 
or torsion. Even direct pressure upon one side of a long bone in a 
child may produce a partial fracture upon the opposite side, which is 
properly an indirect fracture; or a direct blow upon the trochanter 
major may occasion a counter-fracture through the neck of the femur. 

Fractures from muscular action occur most often in the patella, cal- 
caneum, humerus, femur, tibia, and olecranon process of the ulna. 
These accidents may imply some condition of the bones themselves 
which predispose them to fracture ; but I have seen one example of a 
fracture of the shaft of the femur in a large and perfectly healthy man, 
occasioned by a twist of the leg in rolling tenpins. I have also quite often 
known the tibia and patella to break from natural muscular action 
in persons of uncommon vigor. Fractures sometimes occur in the vio- 
lent contractions of the muscles during convulsions, and where no ab- 
normal condition of the bones could be assumed to exist. Parker, of 
New York, relates a case of fracture of the humerus in a negro preacher, 
which" occurred in the act of gesticulation; also, a fracture of the clavi- 
cle occasioned by striking a dog with a whip ; in another case the hu- 
merus was broken in attempting to throw a peach ; but the most singu- 
lar case of all was a fracture of the humerus caused by an effort to 
extract a tooth. 1 

I have myself seen the clavicle broken in the case of a man who was 
reaching back to lift the top of his carriage ; and another in which the 
humerus was broken in a contest to determine the power of the rotator 
muscles of the forearm. 

Lente has seen both femurs broken in epileptic convulsions, in a 
child twelve years of age. The left femur was broken April 10th, 
1859, at the junction of the upper with the middle third, and the right 
femur was broken at the same point eight months after, and about six 
weeks later he died. The first fracture united with considerable bow- 
ing and shortening. The second did not unite at all. He had been 
subject to epilepsy since he was fifteen months old. 2 

Remarkable examples of fragility of the bones have been from time 
to time recorded. Gibson relates the case of a young man w T ho at the 

1 Parker, New York Journ. Med., July, 1852, p. 95. 

2 Am. Med. Times and Advertiser, July 21, 1860, p. 41. 



GENERAL ETIOLOGY OF FRACTURES. 31 

age of nineteen had suffered twenty-four fractures. Arnott speaks of 
a girl who at the age of fourteen had suffered thirty-one fractures ; Es- 
quirol had in his possession the skeleton of a woman in which were 
found traces of more than two hundred fractures ; and we have had, at 
the Charity Hospital, a man set. 53, who had suffered eleven fractures 
and two dislocations, in whose case both the susceptibility to fractures 
and to dislocations appeared to be hereditary. 1 In most of these cases, 
so far as is known, union occurred rapidly. 

Nearly all of the cases of fractures occasioned by muscular contrac- 
tion seen by me were transverse, or nearly so, and most of them have 
been unattended with shortening, the ends of the bones not becoming 
completely displaced from each other. The example of fracture of 
the shaft of the femur before mentioned, as having been broken in roll- 
ing tenpins, was, however, an exception. The limb was placed by the 
surgeon in charge, upon a double inclined plane, upon the theory that 
in this position no shortening was likely to occur. The bone shortened, 
however, to the extent of an inch or more, and in this position it has 
finally united. 

Intra-uterine fractures are not yet fully explained, but it is probable 
that they, like extra-uterine fractures, may be ascribed sometimes to 
external violence, and at other times to simple muscular contraction, 
both perhaps acting upon bones already somewhat predisposed by a 
peculiar constitutional cachexy. 

November 18th, 1872, a child was brought to me having a fracture 
of the left clavicle, which had united with considerable deformity, the 
point of fracture being at the junction of the middle and outer thirds. 
The mother said that she fell upon her belly about two weeks before 
the birth of the child, striking upon a tub; delivery occurred at the full 
period, in the hands of an uneducated female accoucheur. Four weeks 
later (when I w T as consulted) union was complete. 

Lawrence Proudfoot, of New York, has related a case of compound 
fracture in utero occuring in the practice of Dr. Freeman, which was 
apparently caused by external violence. Mrs. F., set. 38, always 
having enjoyed good health, during the sixth month of gestation, while 
attempting to pass through a very narrow passage, was severely pressed 
upon the abdomen, and immediately experienced a severe pain in that 
region, accompanied with nausea and faintness. The following day, 
uterine haemorrhage, with pain, commenced; and these symptoms con- 
tinued at intervals, in a form more or less severe, up to the period of 
her delivery, which occurred at full time, and was perfectly natural. 
At birth, the right foot of the child, a female, was found to be much 
distorted, and in a condition of valgus with equinus, the outer side of 
the foot being laid against the side of the leg above the external malleo- 
lus. The tibia, also, of the same limb, near its middle, seemed to have 
been the seat of a compound fracture; the two ends of the bone having 
united at an angle slightly salient anteriorly, and the skin presenting 
over the point of fracture an old cicatrix. The soft tissues adjacent 

1 The Physician and Pharmaceutist, Feb. 1870. Report by Armenag Assadoorian, 
House Surgeon. 



32 GENERAL ETIOLOGY OF FRACTURES. 

were considerably thickened. Seventeen months after birth, when the 
child was seen by Drs. Proudfoot, Van Buren, and Isaacs, the foot, 
although much improved by the means employed by Dr. Freeman, was 
still considerably deformed, in consequence of the contraction of the 
tendo Achillis ; on cutting which, the limb was found to be of the same 
length with the other. 1 

Dr. Aristide Rodrigue, of Hollidaysburg, Pa., has communicated a 
case of fracture with dislocation, which he ascribes to a similar cause. 
The woman, when about four months with child, fell on her left side, 
striking upon a board, and hurting herself severely. At the full period 
she was delivered of a well-grown male child. Its left humerus was 
found to be dislocated into the axilla, and both the radius and ulna of 
the same limb had been broken through their lower thirds, but were 
now united by bony callus at an angle of about 45°, and slightly over- 
lapped. In all other respects the child was perfect. It does not ap- 
pear that anything was done to the fracture, and the attempt to reduce 
the humerus was unsuccessful. Four years later Dr. R. saw the lad, 
and found him strong and hearty, the dislocated humerus having grown 
nearly at the same rate with the opposite, but the forearm remained 
" short and deformed as at birth." The hand was of the same size as 
the hand of the sound limb. 2 

Devergie has given an account of a woman, who, w T hen seven months 
with child, struck her abdomen against the corner of a table. Intense 
pain followed, lasting some time. She went her full period, however, 
and the child was then found to have a fracture of the left clavicle, 
the fragments being overlapped somewhat, and united in this position 
by a firm and large callus. 3 A woman also six months gone met with 
a similar accident, and at the full time she gave birth to a feeble 
child, having in one leg a separation of the shaft of the tibia from its 
lower epiphysis. The end of the shaft was necrosed, and projected 
through a wound in the integument. This child died on the thirteenth 
day. 4 

Schubert reports the case of a female delivered before her term, of 
twins, one of whom was born with a fracture of the left thigh, which 
had occurred in utero; the fractured bone had pierced the flesh, through 
which it projected more than an inch, and it was carious. The mother 
stated that about six weeks before the accouchement, during a movement 
of the foetus, she had heard a noise like that produced by breaking a 
stick, and from that moment she had felt pricking pains in her belly. 5 
It is probable that in this instance the fracture was the result of a mus- 
cular action, although it is possible that it was occasioned by the thigh 
having become entangled between the legs of the twin. Similar cases 
have been recorded by Ploucquet, Kopp, Devergie, Carus, Schubert, 
Sachse, Moffat, and Brod hurst. 6 

1 Proudfoot, New York Journ. Med., Sept. 1846, p. 199. 

2 Rodriguo, Amer. Journ. Med. Sci., Jan. 1854, p. 272. 

3 Devergie, Rev. Med., 1825. 

4 Malgalgne, from Archiv. Gen. de M6d., t xvi, p. 288. 

5 Amer. Journ. Med. Sci., May, 1828, p. 223; from Zeitsch. fur Staatsarz. von 
Henke, 7e Erg. Heft., p. 311. Holmes's Surgery, vol. iv, p. 826. 

6 Holmes's Surgery, vol. iv, 827, from Med.-Chir. Trans., vol. xliii, 1860. 



GENERAL ETIOLOGY OF FRACTURES. 33 

In many other examples upon record 1 the explanation is plainly 
enough to be sought for in the abnormal or rachitic condition of the 
bones. Monteggia saw, in a newly born infant, twelve united fractures. 
Chaussier, who has published a memoir upon this subject, mentions 
two very extraordinary cases, in one of which the child presented 
forty-three fractures, and in the other, one hundred and twelve. 2 I 
myself was permitted to see, on the 29th of June, 1853, with Drs. 
Hawley and White, of Buffalo, an infant only four days old, who was 
born at the full time, of a healthy mother, in whom nearly all of the 
long bones were separated and movable at their epiphyses, the motion 
being generally accompanied with a distinct crepitus. The bones were 
also much enlarged in their circumference ; the bones of the forearm 
and the femur were greatly curved; the fontanelles unusually open, and 
the clavicles were entirely wanting. The child was of full size, but 
looked feeble. It died in a condition of marasmus six months after 
birth ; at which time some degree of union had taken place at several 
of the points of separation, the limbs having been supported constantly 
with pasteboard splints and rollers. 

Fractures occurring from violence inflicted upon the child by the 
accoucheur, or from contractions of the neek of the womb while the 
child is in transitu, are more common occurrences, and do not require 
a separate consideration. I shall mention several in connection with 
the various bones in which they have taken place ; among which, one 
of the most interesting is that published by Jacob H. Vanderveer, 
of Long Branch, X. J. The mother came to bed on the 18th of 
January, 1847, after a labor of more than twelve hours. It was a foot 
presentation ; the child weighed fourteen pounds, and was perfectly 
healthy, but one of the thighs had suffered a complete fracture, occa- 
sioned probably by the strong contractions of the cervix uteri. With 
careful splinting and bandaging, the bone was finally, but not without 
some difficulty, kept in position and made to unite, so that at the date 
of the report one would not discover that the bone had been broken, 
except by close inspection. 3 



CHAPTEE III. 

GENEKAL SEMEIOLOGY AND DIAGNOSIS. 

Fractures are liable to be confounded with contusions, and with 
various other local injuries, but most often with dislocations; and 
especially when the fracture has taken place near one of the articu- 
lations is the differential diagnosis sometimes rendered exceedingly 

1 Lond. Med. Times and Gaz., April 7, 1860. New Orleans Med. Journ., Nov. 
1860. 

2 Chaussier, Bullet, de la Faculte de Med. de Paris, 1813, p. 301. 

3 Vanderveer, Amer. Journ. Med. Sci., May, 1847, p. 378. 



34 GENERAL SEMEIOLOGY AND DIAGNOSIS. 

difficult. It is with particular reference, therefore, to the general points 
of distinction between fractures and dislocations, that I now propose to 
speak. The special signs or points of difference which belong to each 
individual case will be considered in their proper places. 

The most important general or common signs of a fracture — and by 
"common" signs I mean those which are common to most fractures — 
are crepitus, mobility, and an inability on the part of the fragments 
to maintain their positions when reduced ; indeed, in many cases, this 
constantly recurring displacement is due to the fact that the surgeon 
is unable to accomplish a complete reduction. While, on the other 
hand, dislocations are almost as uniformly characterized by the absence 
of crepitus, by preternatural immobility, and by the fact that, when re- 
duced, the bones do not usually require support to retain them in place, 
or indeed, we may say, by the fact that they are generally reducible. 

Let us study these phenomena a little more in detail. 

Crepitus, occasioned by the chafing of the broken surfaces upon 
each other, when actually present, is almost positive evidence of the 
existence of a fracture. It is possible, however, to confound the chaf- 
ing of engorged tendinous sheaths, or of inflamed joints upon which 
fibrinous effusions have occurred, or of emphysema even, for the true 
crepitus of a fracture ; but to the experienced ear and well-practiced 
touch these sensations are seldom a source of error. The one is rough, 
crackling, or even clicking sometimes, while the other is more sub- 
dued, and imparts a more uniform sensation to the hand, and but 
rarely conveys an actual sound, unless the ear is directly applied or 
the stethoscope is employed. It is only when the crepitus is trans- 
mitted obscurely through a great mass of soft tissues, or sufficient 
time has elapsed for the ends of the fragments to become softened by 
inflammation and partially covered with a plastic material, or when, 
indeed, a dislocation is actually coincident with the fracture, that the 
surgeon is left in doubt. Occasionally, also, the existence of caries or 
of necrosis, in connection with a dislocation, might lead to the sup- 
position of a fracture; but the history of the case, aside from the 
remaining common signs, and the special symptoms hereafter to be 
enumerated, would prevent any possibility of error. In a few cases 
the diagnosis may be facilitated by the application of the ear or of the 
stethoscope, as first recommended by Lisfranc. 1 

It must not be forgotten, moreover, that a fracture at one point 
may transmit the sensation of crepitus distinctly enough, but in such 
a direction, owing to the relations of other bones to the one broken, 
as to mislead the surgeon, and induce him to locate the fracture in the 
wrong bone. Several examples of this species of deception I shall 
hereafter have occasion to mention. 

Valuable and important as is crepitus in its relations to differential 
diagnosis, unfortunately it is not always present, and for reasons which 
must be plainly stated. First: we cannot, in a pretty large proportion 
of cases, bring the broken ends again into apposition. Whatever mere 
theorists may say to the contrary, and notwithstanding surgeons up to 

1 New England Med. Journ., 1824, p. 220. 



GENERAL SEMEIOLOGY AND DIAGNOSIS. 35 

this time have rarely ventured to allude to this subject, the fact is that 
we do not usually " set" broken bones. We do not, even at the first, 
bring them into complete apposition, unless it is as the exception. I 
speak of bones once completely displaced by overlapping, and these 
constitute the majority of examples which come under the surgeon's 
observation. Second : in transverse fractures of the patella, and in 
fractures of the olecranon process of the ulna, of the acromion process 
of the scapula, and in all similar detachments of processes and apophy- 
ses, the action of the muscles, by displacing the fragments, may pre- 
vent crepitus from being readily produced. Third : in a few cases, 
such as certain fractures of the neck of the femur, of the neck and 
head of the humerus, in a Colles fracture, etc., the broken ends may be 
impacted, or so driven into each other as to forbid the production of 
motion and crepitus; or they may be simply denticulated, and the 
consequences, so far as crepitus is concerned, will be the same. 

Finally, in very many incomplete fractures, crepitus does not exist- 
and even when it is present, the sensation is feeble, or very much modi- 
fied, sometimes giving only a faint and single click. Under the head 
of crepitus we may properly include the sharp crack sometimes felt, or 
even heard, by the patient at the moment of fracture. 

Preternatural mobility, less valuable as a means of diagnosis than 
crepitus, is, nevertheless, more constantly present, being never absent, 
in some degree, in all complete, non-impacted, and non-denticulated 
fractures ; but its presence does not, like crepitus, render the existence 
of a fracture quite certain. Whenever the bony lesion takes place in 
the vicinity of a joint, it may be difficult or impossible to determine 
whether the mobility of the limb is due to motion in the joint or to 
motion at the supposed seat of fracture. While, on the other hand, 
the preternatural immobility so generally observed in dislocations may 
give place to preternatural mobility, as when the ligaments and ten- 
dons surrounding the joint are extensively torn, or the system itself is 
laboring under the shock of the accident, or when from any other cause 
there exists great general prostration. 

As to the third common sign mentioned, namely, that in the case of 
fractures the bones do not generally support themselves, but demand 
for this purpose the interposition of splints, bandages, and even of ex- 
tending and counter-extending forces, its authority rests upon the same 
evidence as does the assertion already made, that bones once separated 
entirely, cannot generally be " set," that is, placed again end to end in 
such a manner as to be made effectually to support each other. It 
rests upon the evidence of my own personal experience; to which I am 
permitted to add, also, the personal experience of Malgaigne, who, with 
a frankness which does him great credit, and which, I am sorry to 
say, has hitherto found few imitators, remarks : "Second. That over- 
lapping is the most stubborn of all. Here I will add a disagreeable 
truth, which classical authors have kept too much out of sight, namely, 
that it is so stubborn that in an immense majority of cases the efforts 
of art are unable to overcome it." 1 And it must be observed further, 

1 Malgaigne, Traite" des Fractures et des Luxations, Paris ed., t. i, p. 102. 



36 GENERAL SEMEIOLOGY AND DIAGNOSIS. 

that if we shall often find it possible to bring the broken surfaces suf- 
ficiently into contact to develop crepitus, they may still be unable to 
maintain themselves in this position, owing to the obliquity of the line 
of fracture. 

The other common signs of fracture may be briefly stated. Pain at 
the seat of fracture ; swelling ; ecchymosis ; deformity, produced by 
either an angular, transverse, or rotatory displacement of the frag- 
ments, and which is quite as often due to the direction and force of 
the impulse which occasioned the fracture as to the action of the mus- 
cles ; separation of the fragments, as in fractures of the patella and 
olecranon process ; and inability to move the limb, a phenomenon due 
in part to the breaking of the bony lever upon which the muscles 
acted, and in part to the intense pain caused by any such attempts. 
This latter symptom is, however, often entirely absent. It is not 
generally present in impacted fractures, in serrated and partial frac- 
tures, or in many other fractures in which the periosteum has not yet 
completely given way. 

Velpeau was the first, I think, to call attention to the fact that 
patients with broken clavicles could very generally raise the arm above 
the shoulder and even to the head, and I have repeatedly verified the 
observation, notwithstanding the separation of the fragments has been 
complete, and the overlapping considerable. In fractures of the neck 
of the femur and of the tibia it is no uncommon thing for the patient 
to walk some distance after the receipt of the injury. 

As has been previously stated, fractures of long bones, caused by 
muscular action, generally occur near the middle of the shaft, and they 
are usually transverse. Direct fractures are also more nearly trans- 
verse than indirect fractures, but less so than those caused by muscular 
action; while those indirect fractures which are caused by a force 
applied in the direction of the axis of the bone are, in general, very 
oblique. But what is of more importance in connection with diag- 
nosis is, that in this latter class of cases the fracture usually takes place 
near the point upon which the force of the blow is received. Thus, for 
example, a fall upon the hand generally causes a fracture of the lower 
end of the radius — a Colles fracture — or if both bones break, it is 
generally below the middle, and very seldom indeed in the upper third. 
A fracture of the shaft of the humerus near the condyles is a frequent 
result of a fall upon the elbow. The classical fracture of the clavicle, 
at the junction of the middle and outer thirds, is usually caused by a 
fall upon the shoulder. A fall upon the foot causes a fracture, in most 
cases, near the lower end of the tibia, and the same is true, quite often, 
of the lower end of the femur. Exceptions to the rule above stated 
are most commonly met with in advanced life, when falls upon the 
elbow occasion fractures at the surgical neck of the humerus, and falls 
upon the shoulder sometimes cause fractures near the sternal end of 
the clavicle. Similar accidents, in old people, also break the tibia 
near its upper extremity, and the femur within its capsule. 

I cannot dismiss this subject without calling attention to the neces- 
sity of exercising care and gentleness as well as skill in the examina- 
tion of broken limbs. 






GENERAL SEMEIOLOGY AND DIAGNOSIS. 37 

Nothing, in my opinion, betrays a lack of judgment as well as of 
common humanity, on the part of the surgeon, so much as a rude and 
reckless handling of a limb already pricked and goaded into spasms by 
the sharp points of a broken bone. It is not enough to say that such 
rough manipulation is generally unnecessary, it is positively mischiev- 
ous, provoking the muscles to more violent contractions, increasing the 
displacement which already exists, and sometimes producing a com- 
plete separation of the impacted, denticulated, transverse, or partial 
fractures, which can never afterwards be wholly remedied ; augment- 
ing the pain and inflammation, and not unfrequently, I have no doubt, 
determining the occurrence of suppuration, gangrene, and death. 

In proceeding to establish the diagnosis in any case, the surgeon 
should sit down quietly and patiently by the sufferer, so as to inspire 
in him from the first a confidence that he is not to be hurt, at least 
unnecessarily. He ought then to inquire of him minutely as to all the 
circumstances immediately relating to the accident, in order that he 
may determine as nearly as possible its cause, which alone, to the ex- 
perienced surgeon, often affords presumptive, if not conclusive, evidence 
as to the nature and precise point of the injury. From this, he should 
proceed to examine the disabled limb ; removing the clothes with the 
utmost care by cutting them away rather than by pulling ; and when 
completely exposed, he should notice with his eye its position, its con- 
tour, the points of abrasion, discoloration, or of swelling; and not until 
he has exhausted all these sources of information, ought the surgeon to 
resort to the harsher means of touch and manipulation. Nor will his 
sensations guide him to the point of fracture by any other method so 
accurately as when, the patient being composed and his muscles at rest, 
he moves his fingers lightly along the surface of the limb, pressing 
here and there a little more firmly, according as a trifling indentation or 
elevation may lead him to suspect this or that to be the point of fracture. 

The limb, in case of a supposed fracture of a long bone, may now be 
measured with a tape-line, and compared with the opposite limb, having 
first marked with a soft pencil or with ink the several points from 
which the measurements are to be made. 

Finally, if any doubt remains, the limb must be firmly but steadily 
held while the necessary manipulations are performed, for the purpose 
of ascertaining the existence of mobility and of crepitus. Mobility is 
most easily determined by giving to the limb a lateral motion, but, in 
general, crepitus is most effectually developed by gentle rotation. If 
the place of fracture is already pretty well declared by the previous 
examinations, the surgeon should place one finger over the suspected 
point, during this manipulation, by which means the crepitus will be 
more certainly recognized. 

I do not often find it necessary to resort to anaesthetics for the pur- 
pose of insuring quietude and annihilating pain in making these exam- 
inations, since it is seldom that the patient need to be much disturbed ; 
but if the examination is not satisfactory, and the diagnosis is impor- 
tant, I do not hesitate to render the patient completely insensible, after 
which the questions in doubt may be more thoroughly investigated and 
perhaps definitely settled. 



38 REPAIR OF BROKEN BONES. 

The surgeon ought not to forget, however, that while the patient is 
under the influence of an anaesthetic, violent manipulations are no less 
liable to rupture bloodvessels, and to lacerate other tissues, than if em- 
ployed when the patient is conscious. Surgeons have not seemed al- 
ways to understand this, and the result has been that in too many in- 
stances they have inflicted serious and irreparable injury; in one instance 
which came under my notice, the injury thus inflicted caused tetanus 
and death. 

It is scarcely necessary to say that the earlier the examination is en- 
tered upon, the more readily will the diagnosis be made out; and if, 
unfortunately, some time has already elapsed before the patient is seen 
by the surgeon, and much swelling has taken place, the examination 
is still not to be omitted, and whatever doubts remain we must en- 
deavor to remove by repeated examinations, made from day to day, 
until the subsidence of the tumefaction has brought the surfaces of the 
bone again within the reach of our observation. 



CHAPTEE IV. 

REPAIR OF BROKEN BONES. 

It is not my intention to enter very fully into a consideration of the 
process of repair in fractures, preferring to leave this subject where it 
more properly belongs, to the general treatises on surgical pathology. 

I only propose to state very briefly a few practical, and I trust I 
may now say, pretty well-established facts, such as the manner or posi- 
tion in which this reparative material, whenever it is employed, is ap- 
plied to the broken bones, the length of time which is usually required 
for the completion of the process of repair, and the causes which may 
impede or prevent bony union. 

If I think it necessary to say anything more upon this subject, it 
will be simply to announce my belief that the reparative material, con- 
sisting originally of a plastic lymph, is poured out from the vessels of 
the Haversian canals, the medullary tissue, the periosteum, and more 
or less from all of the lacerated tissues which are immediately adjacent 
to the seat of fracture; that after a period, longer or shorter, this lymph 
becomes organized, and begins to receive from the same sources parti- 
cles of bony matter, through which the consolidation is finally effected; 
that the transition from the original plastic material to bone is in adults 
almost constantly through the interposition of connective-tissue, rarely, 
unless in the case of children, through a cartilaginous tissue, and some- 
times through both consentaneously or consecutively; that, perhaps, in 
a few fortunate examples bones unite directly or immediately, without 
the intervention of a reparative material ; and finally, that granulation- 
tissue sometimes becomes transformed into bone, in certain cases of 
compound fractures, or of fractures in which the process of inflamma- 
tion exceeds certain limits. 



REPAIR OF BROKEN BONES. 39 

Dupuytren, enlarging upon the doctrines taught by Galen, Duhamel, 
Camper, and Haller, declared that "nature never accomplishes the im- 
mediate union of a fracture save by the formation of two successive de- 
posits of callus;" one of which is derived from the periosteum and from 
the adjacent tissues, and from the medulla ; while the other, derived, 
perhaps, from the broken extremities of the bone itself, is found at a 
later period directly interposed between these surfaces. The material 
or callus derived from the tissues outside of the bone, and which Galen 
compared to a ferrule, but which Mr. Paget calls " ensheathing," to- 
gether with the material derived from the medulla, compared often to 
a plug, and by Mr. Paget named " interior " callus, are by Dupuytren 
spoken of as the "provisional," or temporary callus, by which the frag- 
ments are supported, and maintained in contact until the permanent 
callus is formed. This temporary splint is completed or has arrived 
at the condition of bone in a spongy form, at periods varying from 
twenty to sixty days ; but it does not assume the character of compact 
bone until a period varying from fifty days to six months has elapsed ; 
after which it is gradually removed by absorption. The second pro- 
cess, by which the ends of the bone are definitively or permanently 
united, commences when the provisional callus has arrived at the stage 
of spongy bones, and is not completed usually within less than eight, 
ten, or twelve months, "when," says Dupuytren, " it acquires a solidity 
greater than the original bone." 

While it is certain that this eminent surgeon and most accurate ob- 
server has described faithfully the various phenomena which usually 
accompany the repair of bones in those animals which were the sub- 
jects of his experiments, and that his conclusions have a certain degree 
of application to the human species, it is equally certain that he erred 
in assuming that in man simple fractures always unite by this double 
process ; yet, such is the power of authority, these doctrines were ac- 
cepted from the first without hesitation or debate, and for nearly half 
a century they have occupied the minds of surgeons, to the almost 
complete exclusion of every other theory. Mr. Stanley was among 
the first to question the solidity of the doctrines of Dupuytren, but it 
remained for Mr. Paget to fully expose their many fallacies ; nor has 
Malgaigne, although not strictly a disciple' of Paget, failed to detect 
certain of these errors. 

I should also do injustice to myself were I not to mention that at 
the very moment when Mr. Paget was making his observations upon 
the specimens in "the large collection of fractures in the museum of 
the University College," I was myself employed in similar researches 
both among cabinet specimens and in the hospitals of this country and 
of Europe; and that the conclusions to which I had arrived were 
nearly identical with, although the inferences were far from being so 
complete in their detail as those to which this distinguished pathologist 
was himself brought. 1 I do not, however, wish to make Mr. Paget 
responsible for any of the opinions upon this subject which I shall 

1 Paper on "Provisional Callus," b} T Prank H. Hamilton. Buffalo Medical 
Journal, Feb. 1853. 



40 REPAIR OF BROKEN BONES. 

hereafter express, except so far as they may be found to agree with his 
own published views. 1 

I think it may now be fairly stated that the repair of bones by the 
double process described by Dupuytren is, in man, only an exception 
to a very general rule ; and that fractures may unite by either one of 
the following modes : 

First. Immediately, or in the same manner that the soft tissues 
sometimes unite, by the direct reunion of the broken surfaces, and 
without the interposition of any reparative material. This happens 
probably sometimes in the spongy bones, and in the extremities or 
spongy portions of the long bones, especially when one portion of bone 
is driven into another and becomes impacted ; as in certain fractures 
of the neck of the humerus or of the femur. 

Second. By interposition of a reparative material between the broken 
ends ; as when the fragments remain in exact apposition, but immediate 
union fails. This is especially apt to occur in superficial bones, such 
as the tibia ; or upon those sides of the bone which are most superficial. 
It is not an unusual circumstance to find the shaft of the tibia during 
the process of union presenting no exterior callus upon its anterior and 
inner surface, whilst the posterior and outer section of its circumfer- 
ence is covered with an abundant deposit. In other cases, however, 
of fractures of the shaft as well as of the epiphyses, the intermediate 
callus secures a prompt union, but no ensheathing callus is ever formed. 

Third. Bones broken and not separated, unite occasionally by the 
process described by Dupuytren, namely, by the formation, first, of an 
ensheathing callus, whilst at the same moment the cylindrical cavity 
becomes closed by a spongy plug, or its canal is merely interrupted by 
a compact septum of bone ; and second, by definitive callus deposited 
between the broken ends. It is probable that this happens generally 
in children, and it is a common mode of union in the ribs, which 
bones, during the whole progress of the union, are necessarily kept in 
motion. My cabinet furnishes many illustrations of ensheathing callus 
in ribs ; and also a few in fractures of the tibia and fibula. 

Fourth. Under similar circumstances, where no displacement exists, 
the fracture may unite by ensheathing and interior callus alone, no in- 
termediate callus ever being formed between the broken ends ; in which 
case it may be properly said that the bone itself has never united, and 
the ensheathing callus, instead of being provisional, is permanent or 
definitive. This was essentially the doctrine of Galen, Haller, and 
Duhamel before Dupuytren added his " fifth period," or the formation 
of definitive callus ; and by these older surgeons it was held to be of 
universal application, except perhaps in the case of children. To this 
doctrine also Malgaigne has returned ; at least to the question, " Is 
there always a definitive callus, or complete union of the fragments ?" 
he has made this laconic reply : " Galen admitted its occurrence, but 
only in young subjects ; it has been obtained in animals, where there 
had been no displacement. I would willingly believe that such is 
sometimes the case in human adults; but I must confess I have seen 

1 Lectures on Surgical Pathology, by James Paget, Phil, ed., 1854, Chapter XI. 



REPAIR OF BROKEN BOXES. 



41 



only the instance above cited, which might just as well be used to 
prove the compact ossification of the provisional callus/' He accepts, 
therefore, the doctrine of Galen as having not merely an occasional 
application, but as explaining the process of union in the large ma- 
jority of cases; and in support of this extreme view he finds that the 
exterior callus, which Dupuytren called provisional or temporary, is 
actually permanent, unless removed by the absorption consequent upon 
pressure. 

To all of which we can only say that an examination of five or six 
specimens in our own cabinet, after having carefully divided them with 
a saw, has furnished only one illustration of union by ensheathing and 
interior callus alone. In each of the other specimens the union was 
completed by definitive or intermediate callus. We cannot, therefore, 
avoid the conclusion that Malgaigne has been deceived as to the rela- 
tive frequency of these different modes of union, and that union with- 
out intermediate callus is exceptional. 

Fifth. When bones are broken and overlap, they may unite by the 



Fig. 4. 



Fig. 5. 




Fracture of the thigh of a turkey; united with the frag- 
ments widely separated. From a specimen in the author's 
cabinet. 

interposition of a callus between the op- 
posing surfaces, that is, by an interme- 
diate callus, but which will differ from 
that described as the second method, in- 
asmuch as the new material will be de- 
posited upon the sides of the fragments 
and not upon their extremities. The 
limb being kept perfectly at rest, and all 
other circumstances proving favorable, 
this union may take place without ajty 
excess or irregularity in the deposit. 
The surfaces will unite firmly where they 
are in actual contact; and smooth and 
well-formed buttresses will fill up all the 
spaces between the bones where they are 
not in actual contact, sufficient generally 
to give the requisite strength to this new 
bond of union. This mode of union will 
be completed sometimes when the two 

j /» ,i i . i i . n Fracture of the shaft of the femur: 

ends of the bones are separated laterally united with an oblique caiius. From a 

an inch Or more from each Other. I have specimen in the author's cabinet. 




42 REPAIR OF BROKEN BONES. 

in my collection the bone of a turkey's thigh (Fig. 4) thus united by a 
transverse bony shaft, although separated more than one inch; and 
what is less common, I possess also a specimen of the adult human 
thigh (Fig. 5), in which an oblique shaft of solid callus has, after many 
months, and while no splints were employed, bound together firmly the 
two opposite extremities of the broken bone. 

Sixth. The fragments being overlapped more or less, and suffering 
unusual disturbance, or the adjacent tissues having been much torn, or 
much blood being effused, so that considerable inflammation is caused, 
the amount of callus will exceed what is necessary for the complete 
union of the bones ; and this redundancy may be deposited around and 
upon the broken ends of the bones, or anywhere in their immediate 
vicinity, in layers, or in masses of irregular shape and size. Even the 
bones which are not broken, but which are near, as in the case of the 
fibula after a fracture of the tibia, may become inflamed, or their cov- 
erings may inflame, and they may also contribute to the general mass 
of bony callus. 

Compound fractures, or rather, we ought to say, fractures accompa- 
nied with granulations and suppuration, obey no uniform law of repair, 
so far as the manner and position of the deposit are concerned ; but they 
come together finally with more or less irregular distributions of ossified 
matter, according to the varying circumstances of imperfect coaptation, 
mobility, etc., in which they may chance to be placed. Occasionally 
the amount of callus is less than occurs in simple fractures, and at other 
times the excess is very great. 

That was, no doubt, a beautiful thought, which ascribed the forma- 
tion of provisional callus to an intelligent efficient cause, which in this 
manner sought to support the fragments until a reunion of their divided 
ends was accomplished. But the beauty of a conception supplies no 
evidence of its truth ; and we have grave doubts whether Nature ever 
allows any interference with her laws even in an exigency, unless by 
the substitution of a miracle. Provisional callus is, in our opinion, 
just as much the necessary result of natural laws, as is definitive. It 
is formed because in that condition of the parts and of the general life 
its formation was inevitable. Whether useful for the purposes of re- 
pair or not, it will, under certain circumstances, exist. In the repair 
of certain fractures, provisional callus, it is conceded, seldom occurs. 
Thus it is with the cranium, the acromion, coracoid and olecranon pro- 
cesses, the patella, and with all those portions of bones which are im- 
mediately invested with a synovial capsule. Will it be affirmed that 
in the examples just named this callus is not formed because it is not 
required ? To us it seems that nowhere could it prove more useful, 
since, with the single exception of the cranium, it is in these very cases 
that the obstacles to a reunion are the most serious. In fractures of 
the patella, olecranon, etc., the action of the muscles tends constantly 
and powerfully to displace the fragments, and gladly would the sur- 
geon avail himself of the assistance of a temporary callus, but it is 
rarely present, at least in any useful degree. So also in fractures of 
the neck of the femur within the capsule, and in other similar cases, we 
cannot say that temporary callus would not be advantageous in facili- 



REPAIR OF BROKEN BONES. 43 

tating the retention of the fragments, yet the "intelligent efficient 
agent" neglects to furnish it. 

The only satisfactory reason which, as we think, can be assigned for 
the absence of callus in these cases, is found in the doctrines we now 
advocate; that is to say, it is usually absent because that amount of 
excitement and irritation is usually absent which alone determines its 
formation. In the case of the olecranon, patella, etc., the fragments 
being separated from each other by muscular. action, so that no painful 
pinchings or chafings occur, and their rough surfaces or sharp points 
being rather drawn away from than protruded into the flesh, no suffi- 
cient provocation exists for the production of inflammation and effusion. 
Hence the failure of provisional callus ; but wherever the fracture 
occurs, and however moderate the action, definitive callus does not fail ; 
still the broken surfaces of the patella and olecranon are softened, and 
smoothed, and covered over with a new matter, which, if contact could 
have been secured and preserved, would certainly have served to con- 
solidate and repair the breach. The natural reparative process pro- 
ceeds, but only the accidental process is omitted. This latter, however, 
is seen again even here, when from other and unusual causes a sur-ex- 
citement is established. 

Temporary callus is not formed upon bones invested with synovial 
membranes, because here, too — as in the neck of the femur — there are 
not so many structures lacerated and irritated, and the supply of this 
effusion must be the less not only in proportion to the less intensity 
of the inflammation, but also to the less amount of structures impli- 
cated. 

Possibly other and more satisfactory reasons may be assigned why 
provisional callus is not formed usually when the neck of the femur is 
broken within the capsule; but we certainly can never admit the com- 
mon, and, as here applied, the too palpably absurd explanation, that it 
is not wanted. It is wanted, and in no case so much as in the one now 
supposed. 

Provisional callus has, therefore, no final purpose, but it is the un- 
avoidable result of certain abnormal conditions. It still occurs every- 
where when against and in the vicinity of the bone there is the requis- 
ite lesion and action, and it will occur as certainly when there is no 
fracture at all, but only a caries, a necrosis, or a simple bony or perios- 
teal inflammation ; and whilst it is doubtless true that in fractures it 
sometimes renders valuable aid to the surgeon, it is equally true that 
it often proves a source of hindrance. 

From these remarks I choose to except fractures occurring in chil- 
dren, in relation to which the observations are not yet sufficiently 
numerous to determine absolutely the laws of repair. If, however, I 
were to venture an opinion based upon a few examinations, I should 
say that in children we may accept with but little qualification the 
doctrine of Dupuytren as already explained. 

Dupuytren, in determining the limits of his "third" period, or of 
that in which a provisional callus is formed of sufficient strength to 
support the fragments, has given what has been usually quoted as the 
natural period within which bones may be said to be united, that is, 



44 GENERAL TREATMENT OF FRACTURES. 

" from the twentieth or twenty-fifth day, to the thirtieth, fortieth, or 
sixtieth." But this depends so mueh upon the age of the patient, his 
general condition of health, the condition and position of the broken 
ends, as well as upon the bone itself, and the point at which it is 
broken, with many other circumstances, that it would be unsafe to es- 
tablish any absolute laws in reference to this point. 

In very early infancy, union is accomplished in half the time re- 
quired in adult life, and it is generally thought to be still more retarded 
in advanced ao;e, but Mal^ai^ne has not found this latter observation 
confirmed by his own experience. Various constitutional causes, as 
we shall hereafter explain more fully, retard bony union. Motion, 
also, sometimes delays consolidation : fragments winch are overlapped 
do not unite as speedily as those which are placed end to end, and 
other complications interfere in a similar manner, such as lesions of 
nerves, of bloodvessels, comminution of the bone, the interposition 
between the ends of the fragments of a blood-clot, a portion of mus- 
cular, tendinous, or other tissue, etc. In general the bones of the 
lower extremities, independently of their size, unite more slowly than 
the bones of the upper extremities. 

Epiphyses, when separated, unite by the same process as fractures of 
the bone. It is affirmed, however, that, when certain epiphyses unite 
with much displacement, the shafts from which they have been sepa- 
rated cease to grow, and the limbs become atrophied. 

For a more complete consideration of the causes which retard the 
union of bones, I beg to refer the reader to the chapter on " Delayed 
Union, and Non-Union of Bones." 



CHAPTEK V. 

GENERAL TREATMENT OF FRACTURES. 

All that has been said in relation to the propriety of handling a 
broken limb gently, when the surgeon is examining the position and 
character of the fracture, is equally applicable to the lifting and trans- 
porting of the patient to his bed, to the removal of the clothing, and 
to the general management of the limb before it is dressed. Rude or 
awkward manipulations, by which needless pain is inflicted, are not 
simply acts of wanton cruelty, but they are sources, and I think I 
may say frequent sources, of inflammation, suppuration, and gangrene. 
Here, as in all the subsequent handlings, everything should be done 
slowly, thoughtfully, and systematically. Yet it is difficult to state 
the precise manner in which the surgeon ought to proceed. Much 
will depend upon the circumstances of the case, something upon one's 
natural tact, and upon the amount of experience, but more, I think, 
upon natural kindness of heart, and social education. The man of re- 



GENERAL TREATMENT OF FRACTURES. 45 

finement and sensibility will know instinctively how to proceed, and 
needs no instruction. They who lack these qualities can never learn, 
and it would be quite useless to undertake to teach them. I sincerely 
wish such men as these latter would find some more suitable employ- 
ment than the practice of a humane art. 

Nearly all fractures present three principal indications of treatment, 
namely : to restore the fragments to place as completely as possible ; to 
maintain them in place; and to prevent or to control inflammation, 
spasms, and other accidents. 

It ought to be regarded as a rule, liable only to rare exceptions, that 
broken bones should be restored to place, or to the position in which 
we hope to maintain them, as soon as possible after the occurrence of 
the accident. If the patient is seen within the first few hours, or be- 
fore much swelling has taken place, we scarcely know the circumstances 
which would warrant an omission to adjust the fragments either end 
to end or side by side, as the one or the other might be found to be 
practicable. We have before sufficiently explained the general impos- 
sibility of again restoring to place, end to end, and fibre to fibre, frag- 
ments which have been made to override. We are therefore in no 
danger of being understood to say that bones should in all cases be 
immediately " set," in the popular sense of this term. They ought to 
be "set," no doubt, if this can be accomplished through the application 
of a prudent amount of force ; but if they cannot be thus placed end 
to end, they may at least be laid in such a manner side by side as to 
restore, in some measure, the natural axis of the limb, and prevent the 
points of the bone from pressing unnecessarily into the flesh. 

Experience has, indeed, furnished us with four or five very good 
reasons why broken bones should be reduced as soon as possible. 
When the injury is recent, the muscles offer less resistance ; their re- 
sistance being increased after a time not only by the reaction which 
ensues upon the shock, but also by actual adhesion between their 
fibres; effusions distend both the muscles and the skin, and compel 
the limb to shorten ; the constant goading of the flesh by the sharp 
points of the broken bones increases the muscular contractions ; the 
patient will submit readily to manipulation and extension at first, but 
after the lapse of a few days it is very seldom that he will permit the 
limb to be in any manner disturbed, even if he is assured that his 
refusal entails upon him a great deformity. If it is true that no callus 
or bony structure is deposited earlier than the seventh or tenth day, 
it is also true that the renewed attempt to adjust the bones at this 
period, by chafing and tearing again the tissues, reduces the fracture, 
in some degree, to the same condition in which it was at first, and, 
consequently, the time which has elapsed, or, at least, a portion* of it, 
may be regarded as lost. 

We cannot, therefore, understand the argument by which Brom field, 
South, and a few other surgeons have persuaded themselves, that reduc- 
tion should never be attempted before the third or fourth day ; nor, 
indeed, do we fully appreciate the refinement which Malgaigne has 
given to this question, in itself so simple. To affirm that we ought not 
to reduce the bones to their original positions during the period of 



46 



GENERAL TREATMENT OF FRACTURES. 



intense inflammation, or of great swelling, or while the muscles are 
acting spasmodically, is only to affirm that we may not do what is 



Fig. 6. 



Fig. 7. 






,,n w> 


piiii 


•"'""/fjrnn^. 


hut. 


-tM 7 


flE 


'"W 


fe: : 


g_ 


■Willi} 


^ 


""tWIWHS" 




Many-tailed bandage. 






Application of the " roller" by circular and 
reversed turns. 



impossible; and the attempt to do 
which, therefore, can only be mis- 
chievous; but to authorize their 
restoration to a better position, 
by such manipulation, extension, 
and lateral support as they may 
comfortably bear, is warrantable 
under any circumstances. The 
practice is not only defensible, 
but imperative, and we do not 
think any really sound and prac- 
tical surgeon ever intended to 
teach the contrary. We say still, 
if bones can be easily reduced, or 
the position of the fragments improved at any moment, or under any 
circumstances, it ought to be done ; and if we fail in accomplishing all 
that we wish to do in the first instance, we must remain incessantly 
watchful to seize the earliest opportunity which presents, to complete 
the adjustment. No doubt our efforts will prove fruitless very much 
in proportion to the amount of swelling, inflammation, or muscular 
spasm which exists, and also in proportion to the time which has 
elapsed ; but this will not excuse us for omitting to do all which the 
circumstances permit. 

It has been the practice of most surgeons, for a long period, to cover 
the broken limb with some form of a bandage or roller before applying 
the lateral splints. 

Of these primary dressings there are two principal varieties : first, 
the "roller" or simple bandage, applied to the limb in circular and 
reversed turns; and, second, the "many-tailed bandage/' consisting of 
a piece of muslin, or other cloth, torn down from each side into a 
suitable number of strips, leaving the centre, which is to be applied to 
the back of the limb, entire. 

A modification of this latter bandage consists of a number of separate 
strips, so laid upon one another, commencing from above, as that each 



GENERAL TREATMENT OF FRACTURES. 



47 



strip shall overlap the other by one-third or one-half of its breadth. 
This is called the bandage of Scultetus, and it possesses one advantage 
over the many-tailed bandage just described, especially in the case of 
compound fractures, in the facility with which each separate piece 
may be removed and another substituted. Some surgeons prefer to 
form the bandage of separate strips, and having overlaid them in the 
manner directed, to unite them again into one by running a thread 
through the whole mass along the centre. 

Whichever of these several varieties of strips are employed, the 
mode of applying them is the same. They are folded alternately 
around the limb, being made to overlap and cross upon each other in 
front, and only the last strip or two is fastened with a pin. 



Fig. 8. 



Fig. 





Application of the many-tailed bandage. 



Bandage of Scultetus. 



The object proposed in the use of the roller or of the many-tailed 
bandage is twofold : first, to compress and support the muscles, by 
iwhich their tendency to contraction is in some measure controlled ; and 
second, to protect the limb against the direct pressure of the side 
splints. 

A moment's consideration will convince us that the first of these 
objects is in most cases fully attained by the lateral splints themselves, 
and by the bandages by which they are retained in place ; and that the 
second can be as well accomplished by a single fold of cloth, or by the 
compresses, which ought generally, even when the roller is used, to 
underlie the splints. Nevertheless, we should hardly feel authorized 



48 GENERAL TREATMENT OF FRACTURES. 



in- 



to reject these primary dressings solely because the splints and co 
presses furnish a convenient substitute, especially since we are com- 
pelled to admit that they are occasionally useful, unless objections of a 
more serious nature could be brought against them. Unfortunately 
this latter supposition is actually true. By ligating the limb com- 
pletely, leaving no point of the tegumentary surface to which the 
pressure is not applied, they too often occasion congestion, inflamma- 
tion, and gangrene. It is not until lately that the attention of surgeons 
has been sufficiently called to this subject; but the records of surgery 
are to-day filled with these terrible accidents, formerly attributed to 
the original injury or to the splints themselves, but now understood to 
be plainly traceable to the too common employment of the primary 
bandage. The roller is by far the most dangerous dressing of the two, 
since it does not yield to the swelling so readily as the bandage of 
strips, and it is more objectionable also on account of the inconvenience 
of applying and removing it; but even the bandage of strips may be so 
confined as to produce the same consequences, as I have myself seen in 
more than one instance. It is also all the more dangerous in the hands 
of the inexperienced surgeon, because he feels a confidence that it will 
not cause ligation. 

Except in rare cases and for especial reasons, which we shall attempt 
to indicate in their appropriate places, we cannot recommend the em- 
ployment of any kind of bandages next to the skin. 

In order to fulfil the second indication, namely, to maintain the frag- 
ments in place, we employ usually what are called short, side, or coap- 
tation splints, and long or extending splints, or the weight and pulley. 

Side-splints may be constructed from various materials, according 
to the size and circumstances of the limb, or according to the conve- 
nience of the surgeon ; and as the surgeon cannot be expected to have 
always on hand, at the bedside of the patient, such splints as he might 
prefer to use, it is well for him to understand how to avail himself of 
such materials as may be within his reach, in order that he may make 
the most of his sometimes imperfect resources. 

Lead, sheet-iron, zinc, and other metals have been occasionally em- 
ployed, but especially tin and copper, which possess all of the requisite 
firmness and malleability to allow them to be hammered, and thus 
moulded to the limb. In general, however, they are unnecessarily 
heavy, and demand too much labor to be wrought into shape. I have 
sometimes employed tin splints perforated with large fenestra? to dimin- 
ish their weight and increase their flexibility, and found them to answer 
an excellent purpose. The light perforated zinc splints, introduced 
into the U. S. Army by the Sanitary Commission, through the agency 
of Dr. E. Harris of New York, were found exceedingly useful. 

Iron-wire splints, made from wire-cloth or coarse gauze, were first 
publicly mentioned, so far as I can learn, in a communication to the 
Memphis Medical Recorder, made by Dr. J. C. Nott, of Mobile ; but 
they have been brought more particularly into notice, and their con- 
struction perfected, by Louis Bauer. 1 These splints are moulded upon 

1 Nott and Bauer, Buf. Med. Journ., vol. xii, April, 1857. 



GENERAL TREATMENT OF FRACTURES. 49 

" gypsum or wooden casts," of different sizes, and surrounded with a 
stout iron wire frame, in order to give them the requisite degree of 
firmness, and to preserve their forms ; after which they are tinned by 
galvanism, and varnished, to prevent them from becoming rusted. 
When applied, Dr. Bauer recommends that they shall be filled with 
loose cotton, and that they shall be held in place by rollers. It is 
claimed for these splints that they are light, flexible, permeable to air 
and to the perspiration, and that they permit the application of cool- 
ing lotions without impairing their firmness ; the last of which is a 
quality of questionable value, since lotions applied to permanent dress- 
ings of any kind are only warm fomentations, and do not, therefore, 
in this respect serve the purpose for which they are intended. They 
render the skin tender, and disposed to vesicate, and they, also, give 
rise to a sensation of scalding, which is sometimes almost intolerable. 
The water soaks into the bed, and in many other ways renders the 
patients uncomfortable. Lotions are only applicable where the dress- 
ings are open, loose, and temporary. 

The same objections hold, also, to this as to all other forms of 
moulded metallic, or carved wooden splints, namely, that they seldom 
exactly fit the limb, even when the supply of assorted sizes is complete, 
and that they are not sufficiently flexible to adapt themselves to any- 
thing but the slightest irregularity of surface. They are not, however, 
without merit, and they deserve at least a qualified commendation in 
many cases. 

Horn and whalebone may be employed in thin plates, or in the form 
of narrow strips quilted into cloth ; but they are expensive, and possess 
no special value except in an emergency. Reeds, the coarse rank grass 
which grows in swamps, flags, willow branches,, and unbroken wheat 
straw, may be quilted between two thicknesses of cloth in the same 
manner, and form very excellent temporary splints. I have especially 
found t convenient to use wheat straw in the form of junks. Gather- 
ing up a bundle of unbroken straws of the size of my arm, I roll them 
snugly in a broad piece of cotton cloth, cut off the projecting ends, and 
then stitch up the cloth neatly. We have thus a splint of considerable 
firmness, and one which is cool and especially adapted to the summer, 
allowing the perspiration to evaporate freely. Straw splints were em- 
ployed sometimes by Ambroise Par£, by J. L. Petit, Larrev, and I have 
seen them in the wards of certain European hospitals, although I am 
unable now to say under whose direction. Mr. Tuffnell, of Dublin, 
has especially recommended them in the form of junks. 1 

Wooden splints, made of pine, willow, white or linden wood, or of 
some other light and easily wrought timber, are probably of more 
general application, and possess greater intrinsic value than splints 
constructed from any other solid material; but I wish at once, and for 
all, to disclaim any intention of giving even a qualified approval of 
any of those carved, polished, and generally patented wooden splints, 
which are manufactured and sold by clever mechanics, and which one 
may see suspended in almost every doctor's office, whether in the city 

1 Tuffnell, New York Journ. Med., March, 1847, p. 264. 



50 GENERAL TREATMENT OF FRACTURES. 

or in the country. Constructed with grooves and ridges, and variously 
inclined planes, for the avowed purpose of meeting a multitude of indi- 
cations, such as to protect a condyle, to press between parallel bones, 
to follow the subsidence of a muscular swelling, etc., they never meet 
exactly a single one of these indications, whilst they seldom fail to 
defeat some other indication of equal importance. They deceive espe- 
cially the inexperienced surgeon into the belief that he has in the splint 
itself a provision for all these wants, and consequently lead him to 
neglect those useful precautions which he would otherwise have adopted. 

If carved wooden splints are employed, they ought to be made espe- 
cially for the case under treatment. But this requires time and some 
more mechanical skill than can always be commanded ; and when ac- 
curately fitted, it is quite probable that the subsidence or increase of 
the swelling will, within the next forty -eight hours, render some change 
in the form of the splint necessary, or compel the surgeon to throw 
it aside. 

We much prefer to use plain, straight strips of wood, of the requisite 
width and length, which may be cut at any moment from a shingle or 
a thin piece of board ; but in order that these splints may adapt them- 
selves to the inequalities of the limb, and properly support the frag- 
ments, they ought to be covered with a muslin sack, open at both ends; 
into which, and on the side of the splint which is to be placed against 
the limb, bran, wool, oakum, curled hair, or cotton batting, may be 
pressed, until it is made to fit accurately. I generally prefer cotton 
batting. Bran is liable to get displaced, and curled hair does not pack 
firmly enough. When the sack is sufficiently filled, the two ends must 
be stitched up. This mode of constructing the splint is simple and 
easy of accomplishment ; the splint can be fitted very accurately ; the 
padding never becomes displaced ; and when the bandages are applied, 
they may be pinned or sewed to the cover in such a way that they 
shall not slide or loosen. 

If pads are employed separate from the splint — and for this purpose, 
also, I generally prefer the cotton batting — they ought to be made and 
fitted with the same care, and neatly stitched together at their ends, 
rather than pinned. Cotton batting laid loosely next to the skin, or 
underneath the splints at any point, will not keep its place so well as 
when it is inclosed in covers — it is more liable to get into knots, and 
it has altogether a slovenly appearance. The pads may be stitched to 
the roller, and in this way secured effectually in place, but loose cotton 
is subject to no control. 

When I speak of pads, it must not be understood that I intend to 
recommend them for compresses, or for the purpose of pressing frag- 
ments into place. Nothing could be a greater source of mischief in the 
dressing of a broken limb. I have only directed their employment as 
a means of adaptation, and to protect the skin against the direct pres- 
sure of the splint. 

Dr. Jacobs, of Dublin, says that he has seen an excellent splint made 
from the " fresh bark of a tree, taken off while the sap is rising." " It fits 
admirably," says Dr. Jacobs, "just like pasteboard soaked in water." 1 

1 Jacobs, New York Journ. Med., March, 1847, p. 265, from Dublin Med. Press. 



GENERAL TREATMENT OF FRACTURES. 51 

Dr. C. C. Jewett, of the 20th Mass. Vols., recommends for the same 
purpose the bark of the liriodendron, or tulip tree. 

Hemlock-tanned, undressed, sole leather, cut into shape and soaked 
a few minutes in water, adapts itself easily to the limb and is sufficiently 
firm. It is especially applicable to fractures of the larger limbs. At 
Bellevue Hospital it has for several years taken the place of almost all 
other materials, for the construction of movable splints. Oak-tanned 
leather is less flexible than the hemlock-tanned, and does not make so 
good a splint. The specimens selected should be of medium thickness. 
Before applying the splint the edges should be bevelled on the inner 
side, and the corners rounded, and a piece of woollen cloth should be 
interposed between the splint and the skin. The leather will become 
hard within twenty-four hours, and at the next dressing it may be re- 
moved, covered with a sack made of woollen or cotton cloth and replaced. 

A splint is also occasionally made of thin calfskin, veneered with 
some light timber, such as linden or white wood, the latter being sub- 
sequently split into strips of from half an inch to 
one inch in width, so as to combine a certain de- 
gree of flexibility with the requisite firmness. 

The Turks use, according to Sedillot, in a similar 
manner, the "nervures" of palm, laid upon sheep- 
skin, and fastened with wooden thongs ; l and Pack- 
ard mentions that he has seen narrow slips of some 
light wood glued in the same way upon soft pieces 
of buckskin, and then fastened together with two 
strips of buckskin, which were also glued to the 

Hn ]J n fc 2 Wood and leather splint. 

Common, unpolished pasteboard, cardboard, or the stout millboard 
used by bookbinders, constitute invaluable domestic resorts, since they 
can generally be found in the house of the patient ; and if in no other 
way, pasteboard may generally be had at the expense of some paper 
box or of the loose cover of some old book. For small bones, the 
thinner sheets afford a sufficient support ; but for large bones the thick 
binder's board is necessary. In preparing the latter for use, it ought 
to be moistened with water ; but if soaked too much it will separate 
and fall into pieces, or lose its firmness when dry, in consequence of 
having parted with some of its paste. This splint may be applied to 
the limb without the interposition of anything but a few folds of 
muslin cloth, or a piece of flannel; or we may use instead a single 
sheet of cotton wadding. It must be bound to the limb by the roller 
while it is moist ; and, as it dries speedily, it forms a smooth, firm, and 
reliable splint. 

Felt, made of wool saturated with gum shellac, and pressed into 
sheets, makes an excellent moulding tablet for splints. This may be 
obtained at any hat manufactory. Until recently they were manufac- 
tured, and moulded into a great variety of forms, by Dr. David A his,. 
at York, Pennsylvania. A much cheaper material, however, and 
which has nearly all the qualities of the real felt, may be made from 

1 Amer. Journ. Med. Sci., vol. xxiii, Feb. 1839, p. 481. 

2 Packard's edition of Malgaigne, vol. i, p. 173. 




52 GENERAL TREATMENT OF FRACTURES. 

old pieces of broadcloth, or from any similar closely woven texture, by 
saturating it thoroughly with gum shellac, the gum being dissolved in 
alcohol in the proportions of one pound of the former to two quarts 
of the latter. Thus prepared, it is to be spread upon both surfaces of 
the cloth with a common paint-brush. When this first coat is well 
dried by suspending the cloth where the air will have free access to 
both surfaces, a second must be spread upon one of the surfaces ; and 
then a third ; the cloth being allowed to dry after each successive 
coat. Finally, the sheet is to be folded upon itself, so as to bring the 
most thickly covered surfaces together, and pressed with a hot flatiron. 
If it is necessary to have greater strength, more gum may be laid upon 
the cloth, and it may be again folded and pressed. When used, it is 
to be dipped into boiling water or held near the fire until it becomes 
flexible. It hardens very rapidly in cooling, and demands, therefore, 
some quickness in its application ; but once applied and fitted, it forms 
a hard but smooth splint, well adapted for all the purposes for which 
it is designed. It is well to mention, if one wishes to keep any por- 
tion of the solution which is not used, that, in order to prevent evapo- 
ration, the vessel in which it is contained must be closely covered. I 
have recently seen a similar splint made of strong canvas cloth, satu- 
rated with gum shellac, for sale by the instrument-makers in this city. 

The principal objection to all of those forms of splints which contain 
gum shellac is, that they harden so rapidly after being made flexible 
by exposure to heat, that it is often found difficult to give them an ac- 
curate mould to the limb. 

Dr. Jacobs says he has sometimes found an old hat to furnish a very 
efficient splint in the small fractures of children. 

It has been objected to the felt splint occasionally, that it is imper- 
vious to air and moisture, and that it confines the insensible perspira- 
tion; an objection which may be obviated in some measure by rubbing 
the surface which is to be laid against the limb, with pumice-stone, 
until it is roughened or until a short nap is raised. But as I never 
use splints of any kind without underlaying them with compresses, or 
woollen cloth, which act sufficiently as absorbents, I have never been 
aware of any inconvenience from this source. 

Dr. R. O. Cowling, of Louisville, Ky., has called attention to the 
value of Manilla paper in the construction of splints. 1 A limited use 
of this material satisfies me that it possesses in an eminent degree most 
of the qualities of a good splint. It is cut into strips, stiffened with 
starch and applied longitudinally or spirally, as may be necessary to 
cover the limb completely and smoothly. For the lower extremities 
six to eight layers are required. The material may be obtained at 
most large paper stores. 

Within a few years, sheets of gutta percha have been brought into 
the market, varying in thickness from one-sixteenth to one-quarter of 
an inch; the use of which for side splints was first suggested and prac- 
ticed by Oxley, of Singapore. For fractures of the thigh, and for the 
large bones generally, I prefer a thickness of about one-sixth or one- 

1 American Practitioner, Jan. 1871. 



GENERAL TREATMENT OF FRACTURES. 53 

fifth of an inch ; but for the fingers or toes it need not be more than 
one-sixteenth of an inch in thickness. In its natural state, and at the 
ordinary temperature of the body, it is nearly as hard and as inflexible 
as bone ; but when immersed in hot water it almost immediately 
softens, and would become too soft to be conveniently handled unless 
soon removed. It can therefore be adapted to any surface, however 
irregular, and its form may be changed as often as may be necessary. 
It does not harden as rapidly as felt, and it possesses, therefore, in this 
respect, an advantage, since it allows the surgeon more time for ad- 
justment ; while, on the other hand, it hardens much more rapidly than 
either starch, paste, or dextrin. Ten or twenty minutes is all the time 
usually required for gutta percha to acquire that degree of firmness 
which will prevent it from yielding under the pressure of a bandage. 

To use gutta percha skilfully requires some experience, and I have 
known surgeons to reject it after a single trial ; but by those who have 
acquired the necessary skill it is generally regarded as an invaluable 
resource. 

When constructing from this material a thigh-splint, we should 
order a very large tin pan, or some open, flat tray, in which we may 
lay the splint at full length. If the splint is required to be twelve 
inches long, and six inches wide, we must cut it about fourteen inches 
long by seven wide, so as to allow for the contraction which always 
takes place more or less when the hot water is applied. It is then to 
be laid upon a sheet of cotton cloth of more than twice the width of 
the splint, in order that the cloth may envelop it completely when it is 
folded upon it ; and the cloth should be enough longer than the splint 
to enable us to handle and lift it by the two ends without immersing 
our fingers in the hot water. Beside, if the gum is not thus covered 
and supported, it will adhere to the vessel, to the fingers, to the sur- 
face of the limb, and indeed to whatever else it comes in contact with ; 
it may even fall to pieces, or become very much stretched and distorted 
by its own weight. The cloth cover will generally adhere to the splint, 
and may be permitted to remain upon it permanently. 

Place the splint, thus covered, in the basin, and pour on the water 
slowly. As soon as it is sufficiently softened, lay it over the limb, 
moulding it carefully with the hands, or by pressing it against the limb 
with a pillow. If it does not harden rapidly enough, this process may be 
hastened by sponging the outer surface with cold water; and as soon as 
it has acquired sufficient firmness to suppport itself, it may be removed 
and immersed in a pail of cold water or placed under a hydrant; after 
this, it is to be neatly trimmed and wiped dry, when it is ready for use. 

When gutta percha remains a long time exposed to the air, it gradu- 
ally oxidizes, its color becomes darker, it loses its tenacity and flexi- 
bility. This may be prevented by keeping it constantly immersed in 
cold water. It may be sufficient to place it in a damp cellar. 

The same objection has been made to gutta percha which is occasion- 
ally made to felt, namely, that it confines the perspiration, but to this 
we have already sufficiently replied. 

There is scarcely any fracture demanding the use of a splint in which 
I have not demonstrated its utility, but it is especially valuable, as I 



54 



GENERAL TREATMENT OF FRACTURES. 



Fig. 11. 



shall have occasion to mention again, as an interdental splint in frac- 
tures of the jaw, and as a moulding tablet in all fractures occurring in 
the vicinity of joints. 

Sheets of gutta percha of any required thickness may be obtained in 
this city of Mr. Bishop, the manufacturer, on Twenty-fifth Street near 
the East River. One pound will make about four thigh-splints. 

Benjamin Welch, of Lakeville, Conn., has contrived a very ingeni- 
ous application of gutta percha to the purposes of a splint, by veneer- 
ing a thin plate of the gum with equally thin plates of elastic wood. 
The veneering is laid upon both sides, and then it is pressed into form 
in moulds. The elasticity of the wood, together with the plasticity of 
the gum, enables the surgeon to change its form somewhat at pleasure, 
by dipping it into hot water. Its form cannot, however, be changed to 
any great extent, and by frequent immersion in hot water the veneer- 
ing is apt to loosen from the gutta percha. 

The moulding tablet of Alfred Smee, composed of gum Arabic and 
whiting, spread upon cloth, 1 has nothing special to recommend it, any 
more than the cloth splints, hardened with the whites of eggs and flour, 
used by Larrey. 2 Starch and alum, glue, pitch, and various other ma- 
terials of a similar character deserve only to be mentioned as having 

been occasionally employed, but which 
have never succeeded in securing for 
themselves the confidence of surgeons. 

Immovable, or Permanent Dressings. — 
In 1834, Seutin, of Brussels, introduced 
the use of starch as a means of hardening 
the bandages ; his method of using which 
is essentially as follows : a dry roller is 
first applied to the skin, and then smeared 
with starch ; all of the bony prominences 
and irregularities of the limb are filled 
up or covered with cotton batting, char- 
pie, down, etc. ; strips of pasteboard, or 
of binders' board, moistened and covered 
also with starch, are now laid alongside 
the limb, over which again are turned in 
succession one, two, or three layers of the 
starched roller; the number of rollers 
and the thickness of the pasteboard being 
proportioned to the size of the limb or to 
the required strength of the splint. The 
whole is completed by starching the out- 
side of the last bandage. 

This dressing will generally become 
dry within from thirty to forty hours; 
starch bandages, applied for a broken which process may be expedited by ex- 
thigb. posing its sides as much as possible to 




1 Amer. Journ. Med. Sci , vol. xxvi, p. 220, May, 1840; from London Lancet, 
Jan. 25, 1840. 

2 Amer. Journ. Med. Sci., vol. ii, p. 216, May, 1828; from Journal des Progres, 
vol. iv. 



GENERAL TREATMENT OF FRACTURES. 55 

the air, or by the application of artificial heat with bags of dry sand, 
or with hot bricks. As a temporary support until the drying is com- 
pleted, some surgeons lay upon each side of the limb additional splints, 
securing them in place with tapes. 

As soon as the bandages are dry, they are to be cut along the front 
to a sufficient extent to permit of an examination of the limb, and then 
closed with an additional roller. For the purpose of opening the band- 
ages, both at this period and subsequently, Seutin uses a pair of strong 
scissors or pliers, such as are represented in Fig. 12. 

On the third or fourth day, or as soon as the subsidence of the swell- 
ing may render it necessary, the bandages should be cut open through 
their whole extent, the edges pared off and brought together again 
snugly with an additional roller. 

Fig. 12. 




Seutin's pliers, 



In 1837, Velpeau substituted dextrin (" British gum"); a kind of 
glue or jelly obtained by the continued action of diluted sulphuric acid 
upon starch at the boiling-point. It is prepared for use by dissolving 
it in alcohol or tincture of camphor, or camphorated brandy, until it 
has acquired about the consistence of honey ; at this point hot water 
should be added, reducing its consistence to that of thin treacle, w T hen, 
after one or two minutes' shaking, it is ready for application. Accord- 
ing to F. D'Arcet, the proportions most favorable to the drying and 
solidifying of the apparatus are, one hundred parts of dextrin, sixty 
of camphorated brandy, and fifty of water. Malgaigne, to whom I am 
indebted for this observation of D'Arcet, says, also, in a note, "As 
regards dextrin, an important point was recently brought practically 
under my notice, viz., that, as sold in the shops, it is often unfit for 
making an agglutinative mixture; it forms lumps with alcohol, as 
starch does with cold water, without cohering ; and twice in succession 
I have been obliged to change the supply at the Hopital Saint Antoine. 
The dextrin thus deteriorated is whiter and less saccharine; it crepitates 
more in the fingers ; and on pouring a few drops of tincture of iodine 
into the solution, there is produced a violet tint, indicating the presence 
of fecula ; while true dextrin, treated with iodine, gives a vinous red, 
or the color of onion-peel." 

Velpeau soaked his bandages with the dextrin before applying 
them, but, like Seutin, he applied his first roller dry. He used but 
one bandage, which he carried first from below upwards, and then 
from above downwards ; and he rarely thought it necessary to employ 
the pasteboard as a collateral support. 

A mixture composed of equal parts of precipitated chalk and gum- 



56 GENERAL TREATMENT OF FRACTURES. 

arabic, reduced to a proper consistence by boiling water, applied to 
rollers while they are being applied to the limb, forms a firm and light 
splint. It has the advantage also of hardening quickly. 

Startin and Tait, of London, recommend paraffin, which, being thor- 
oughly melted, is cooled a little, to render it more viscid, and then 
rubbed into the meshes of the bandage, during the process of applica- 
tion with a paint-brush. 

Silicate of soda, of potassa, or of magnesia, have also been employed 
in the same manner. A saturated solution is prepared, and applied 
with a brush. It hardens speedily, and forms a light, firm, and neat 
splint. 

For myself, I have been more in the habit of using wheat-flour paste 
than either of the other materials named, and, if properly made, it dries 
about as quickly as the starch, and is equally as firm. 

Whatever material is used — whether starch, flour paste, dextrin, 
solutions of the silicates, gum shellac, or plaster-of-Paris — in the con- 
struction of what is now usually termed the " immovable apparatus," 
or, as Seutin has more lately called it, the " movable immovable appar- 
atus" (" movo-amobile"), in reference to his practice of opening it at 
an early period, it is still the same apparatus in effect, and is liable to 
the same judgment — a judgment which we shall find it very difficult 
to declare, since, from the day in which this practice was first recom- 
mended by Seutin, to the present moment, it has been constantly ex- 
periencing the most extraordinary vicissitudes in the public favor. At 
one time, and by the most experienced surgeons, extolled as a method 
unequalled in its simplicity, efficiency, and safety; and at another, and 
by surgeons of equal experience, denounced as eminently lacking in all 
of the true essentials of an apparatus for broken limbs. These con- 
flicting opinions, which it is impossible to reconcile, have nevertheless 
some foundation in truth. The immovable apparatus, of whatever 
materials constructed, is under some circumstances a very simple, safe, 
and efficient dressing, while under other circumstances it is, as we 
think, eminently unsafe and inefficient. Thus, in all of those fractures 
which are accompanied with such injury to the soft parts as to render 
subsequent inflammation inevitable or probable, this form of dressing 
exposes to congestion, strangulation, and gangrene. Whatever its ad- 
vocates may say to the contrary, the simple fact is before us, that the 
number of accidents resulting from this practice is out of all proportion 
with any other yet introduced. I have met with them myself in all 
parts of my own country, and the journals abound with records of 
disasters from this source. 1 Nor is it a sufficient reply to this state- 
ment, that, with proper care and prudence, such accidents may be 
avoided. We think they could not always be avoided. But admitting 
that they could, it is still undeniable that in certain cases, the immov- 
able apparatus demands extraordinary attention ; and what is the need 
of multiplying our cares when already they are more than sufficient? 
Many circumstances, over which he has no control, may prevent the 

1 Amer. Journ. Med. Sei., vol. xxv, p. 400, Feb. 1840; also vol. xxxi, p. 212. 
Med. Record, Nov. 1, 1873; New York Med. Journ., Aug. 1874, Oct. 1874. 



GENERAL TREATMENT OF FRACTURES. 



57 



surgeon from giving to the limb the full amount of attention which is 
required ; and for this reason that apparatus is the best which, whilst 
it answers the indications equally well, exacts the least amount of skill 
and attention on the part of the surgeon. 



Fig. 13. 




Opening of the apparatus with Seutin's pliers. 

Immovable dressings are not only liable to become too tight as the 
swelling augments, but, on the other hand, the surgeon may omit to 
notice that as the swelling has subsided it has become loose. Portions 
of the limb may vesicate, ulcerate, or even slough, without the knowl- 
edge of the surgeon. If, however, the bandages are frequently opened, 
and all the proper precautions are taken, it is possible that these acci- 
dents may also be avoided ; but unfortunately experience has shown 
that they have not been avoided in too many instances. 

The cases, then, to which this apparatus seems to be especially 
adapted, are a few examples of transverse or serrated fractures in which 
the bones have not become displaced, and in which little or no swell- 
ing is anticipated; and certain fractures which were originally more 
complicated, but in which a partial union, and the subsidence of the 
inflammation, have reduced them to a more simple condition; and espe- 
cially is it adapted to cases of delayed union. If now the dressings are 
applied carefully, the bandage being only moderately tight; and a 
portion of the extremity of the limb is left uncovered so that we may 
observe constantly its condition, and at proper intervals the apparatus 
is opened completely, in order that we may subject the whole limb to 
a thorough examination ; in such cases as we have now indicated, and 
with such precautions, we admit that the " apparatus immobile " con- 
stitutes an invaluable surgical appliance, and one of which no surgeon 
can well afford to be deprived. 

I have even met with examples of compound fractures in which it has 
seemed proper to apply this dressing ; and especially when a sufficient 
time had elapsed to render it probable that there would be no sudden 
accession of swelling in the limb. In such cases I have preferred 
generally to lay the several turns of the roller directly over the sup- 
purating wound in the same manner as if no wound existed, and to 
make a valvular opening, or window, with the scissors, on the following 
day, in order to allow the matter to escape, after which the valve may 

5 



58 



GENERAL TREATMENT OF FRACTURES. 



Fig. 14. 




ap- 



be laid down and stitched, or the piece may be removed entirely, and 
a new piece of bandage drawn closely around the limb at this point. 
This may be repeated once or twice daily. If 
an opening is left by the roller, and no addi- 
tional bandage or compress is laid over it, the 
margins of the wound soon become oedematous 
and protrude, making an ugly-looking and ill- 
conditioned sore. 

Plaster of Paris moulds, employed occasion- 
ally from a very early period, and more lately 
recommended by Hendriksz, Hubenthal, Key], 
and Dieffenbach, are not entitled to serious con- 
sideration. Heavy stone coffins, they might 
serve well enough the purposes of interment, 
but they are wholly unsuited to the purposes 
of a splint. 

Plaster of Paris has, however, been from a 
later period, employed in another form, as an 
" immovable " dressing. I allude to the so- 
called " plaster of Paris bandages," which were 
first introduced to notice by Mathiesen, of Hol- 
land, in 1852. In 1854, Pirogoff, surgeon in 
chief of the Russian armies, called attention to 
the plaster of Paris dressings, but in a form 
differing somewhat from that employed by 
Mathiesen. 

Recurring to the history of the immovable dressings, as briefly nar- 
rated in the preceding pages, and as more fully recorded in the medi- 
cal journals of the next eighteen or twenty years, we shall find that it had 
steadily declined in public favor, on account of the numerous accidents 
resulting from its use, many of which became the subjects of litigation 
in the A merican courts ; so that neither the suggestions of Mathiesen in 
1852, nor the great name and influence of Pirogoff, in 1854, nor the 
advocacy of Hunt of Birmingham in 1855, nor of Gamgee in 1856, 
were sufficient to secure for plaster of Paris the confidence of the pro- 
fession. The period was unfortunate, and surgeons were scarcely will- 
ing to give these gentlemen a respectful hearing, inasmuch as they at 
once recognized these modes of using plaster of Paris, as only modifica- 
tions of the method of Seutin, which, for good reasons, thay had just 
laid aside. 

Since Mathiesen wrote, however, a new generation has arisen ; a gen- 
eration of active, able, and hopeful men; with no prejudices of experi- 
ence to overcome; to whom the " primary bandage " andSeutin's " ap- 
paratus immobile," convey no apprehensions of danger; and now 
again, following this time the lead of the German surgeons, we find 
these methods in popular favor, both at home and abroad. It will be 
the part of wisdom, while we observe carefully the experience of the 
present, to recall the lessons of the past. 

At Bellevue, during the last six or seven years, plaster of Paris band- 
ages have been used quite extensively, and, after a careful observation 



"Apparatus immobile 
plied over a compound frac 
ture. 



GENERAL TREATMENT OF FRACTURES. 59 

of the results in my own wards and in the wards of my colleagues, I 
find no occasion to recall anything I have said of this, as one form of 
the immovable apparatus, in the preceding pages ; the dangers have 
not been overestimated, yet I must say that in fractures of the leg, 
whether simple or compound, when great care is exercised in the man- 
agement of the case, it is in some respects superior to any other form 
of dressing. I shall describe the cases to which it is applicable, more 
particularly, when speaking of these fractures. I am not at present, 
however, prepared to speak of it so favorably in the fractures of any 
other long bones. 1 

The manner of using gypsum bandages generally preferred at Belle- 
vue Hospital, may be thus briefly described. Thin, rather coarse un- 
glazed cotton cloth, torn into strips, is laid upon a table and the dry 
plaster rubbed into it until its meshes are full. It is then rolled, and 
made ready for use by immersing it a few minutes in hot water. The 
limb, being held in a proper position, is first inclosed in soft dry flan- 
nel cloth, aud the rollers are then applied. In most cases two or three 
thicknesses of bandage are found to be sufficient. A more full descrip- 
tion of this method, known generally as Mathiesen's, will be found in 
the chapter devoted to the consideration of fractures of the femur. 

Another method of using the gypsum bandages, not generally prac- 
ticed at Bellevue, is as follows : A dry roller is first applied to the 
limb, or it may be covered with a single piece of cloth of any kind, 
and the irregularities are filled up and protected with cotton-wool, the 
same as we have directed w r hen about to apply the starch bandage. 
The remaining dressings being now at hand and ready for use, we pro- 
ceed to mix the plaster. For this purpose we must select the fine, 
fresh, well-dried, white powder. The gray does not solidify well, nor 
that which has been a long time ground, or is moist. The proportions 
of water and plaster usually required are about equal parts by weight. 
For the thigh it may require, perhaps, seven or eight pounds of plaster, 
and for the leg or arm much less. It is probably a better rule to 
direct the gypsum to be added to the water until it is of about the con- 
sistence of cream. The water should be cold and the gypsum thrown 
in not too rapidly, at least not more rapidly than it can be thoroughly 
mixed, otherwise we shall not be able to determine precisely its con- 
sistence. If, while applying the paste, it begins to harden in the bowl, 
we must not add more water, as this will again interfere with its final 
solidification upon the limb. It must be thrown away and some fresh 
immediately prepared ; or the crystallization may be retarded by throw- 
ing in a few drops of carpenters' glue, or a little starch, dextrin, or 
glycerin. The solidification may be hastened by adding a little salt to 
the water. When the plaster is good, and it is properly mixed, we 
may allow ourselves from five to eight minutes in the application. A 
large paint-brush is the most convenient thing for spreading it, but the 
hands will do very well in an emergency. 

1 Treatment of Fractures of the Femur by the Immovable Apparatus, b}' the au- 
thor. New York Med. Journ. Au#. 1874. A comparison of the results of treatment 
of 308 fractures of the thigh at Bellevue Hospital, by Frederick E. Hyde, M.D. 



60 GENERAL TREATMENT OF FRACTURES. 

Everything being ready, the limb is to be seized by assistants at 
both of its extremities and held in a position of steady extension until 
the dressing is completed, and for several minutes longer, or until the 
plaster is hard. The surgeon then proceeds to lay a long piece of 
linen — old sack will answer as well as any — folded three or four times, 
and saturated with the paste, parallel to the two sides of the limb, 
around which are to be immediately placed, horizontally and at several 
points, short and wide strips of the same material. These latter are 
intended to increase the strength of the apparatus, and to bind on the 
side strips. Finally, the whole may be painted with the solution. It 
is very well, however, not to cover the front of the limb, or a narrow 
strip somewhere in the line of the axis of the limb, with the plaster, as 
this will not diminish materially its strength, and it will enable the 
surgeon to open it more easily with the scissors. PirogofF accom- 
plishes the same purpose by laying a piece of narrow tape, soaked in 
oil, along the line through which he wishes to make the section of the 
splint. 11 

Prof.. James L. Little, of this city,. makes his plaster splints of two or 
three thicknesses of muslin, or of canton flannel, which being saturated 
with fluid plaster, are laid upon the limb previously shaven and oiled, 
and secured in place with a roller.. He advises that the roller shall 
be removed as soon as the plaster is set and a fresh one applied, which 
can afterwards be easily removed. 2 

Some surgeons prefer to construct the plaster splint in the following 
manner t Two* pieces of flannel are laid one upon the other, and being 
stitched by a straight seam along the centre, the inner layer is carefully 
folded around the limb, and made fast by a needle and thread. Fluid 
plaster is now spread over the outer surface of the inner layer, and the 
inner surface of the outer layer, when the two are brought in contact 
upon the limb, and the whole secured by a roller. After the splint is 
thoroughly dry it may be cut in front and opened like the cover of a 
book. Hence it has been called the " book-back " method. It is also 
known as the Bavarian.. 

There are other modifications of the methods of using plaster of 
Paris, which will be more appropriately described in connection with 
special fractures. 

In removing the plaster we generally employ a shoemaker's knife, 
softening the plaster as we proceed, with a sponge dipped in hot water. 
As cutting pliers for this purpose, no instrument has been found suf- 
ficiently powerful except that introduced by Dr. Victor von Brun, of 
Tubingen. 

Professor B. W. Dudley, of Lexington Ky., one of the most success- 
ful surgeons in this country, but especially distinguished as a lithoto- 
mist, for many years employed in the treatment of fractures nothing 
but a roller, regarding both side-splints and extending apparatus as 



1 Weber on Plaster of Paris Bandage, New York Journ. Med., May, 1856, p. 341. 

2 Little. On the Use of Plaster of Paris, in the Treatment of Fractures, by James 
L. Little, surgeon to St. Luke's Hospital, etc. Med. Eec, Nov. 1, 1873. 



GENERAL TREATMENT OF FRACTURES. 61 

not only useless, but absolutely pernicious. 1 This practice, which 
seems to have originated with Radley, of England, has not found, 
hitherto, in this country or elsewhere, many imitators. 

Fig. 15. 




Von Brim's plaster-cutter. 

Still more unscientific and irrational was the practice of Jobert, of 
Paris, who employed neither side-splints uor bandages^ but only exten- 
sion, in the treatment of all, or of nearly all fractures of the long bones. 
The side or coaptation splints bring the fragments into more complete 
apposition, and secure a more prompt and certain union. They ought, 
therefore, never to be omitted, unless the condition of the limb pre- 
cludes their application. 

As to the question of permanent extension in fractures, and the 
means by which it may be most effectually accomplished, nothing need 
be said at this time, inasmuch as it relates only to the fractures of 
certain bones, and to certain forms of fractures ; we must therefore 
refer its consideration to those chapters which treat of individual 
bones. 

In the treatment of comminuted fractures, no pains 'ought to be spared 
to bring the fragments as nearly as possible into apposition ; and if 
there exists at the same time an external wound, and the fragments are 
small and loose, they ought to be removed carefully. Xor, indeed, 
should we be deterred from the attempt to remove them by finding 
that they are somewhat adherent, if still they are very easily moved 
about with the finger. 

In compound fractures, not unfrequently the end of one of the frag- 
ments protrudes from the wound, and its reduction mav be attended 
with considerable difficulty. My practice is usually in such cases to 
attempt the reduction first, by simple extension and counter-extension.; 
but if this fails, I introduce ray finger into the wound, and endeavor to 
stretch the skin over the sharp point of bone; or I make use of a 
spatula formed from a piece of shingle, or of any suitable piece of 
metal which may be at hand ; finally, but not until all other expedi- 
ents have failed, I enlarge the wound sufficiently to insure its return. 
Anaesthetics may be employed, also, to facilitate the reduction. 

1 Dudley, Trans. Amer. Med. Assoc, vol. iii, 1850, p. 349. 



62 GENERAL TREATMENT OF FRACTURES. 

There are some cases, however, in which the surgeon may feel justi- 
fied in sawing off the projecting end ; as when the periosteum is com- 
pletely torn from it by its having penetrated a boot, or even sometimes 
when its extremity is very sharp, and there is reason to suppose that it 
would prick and irritate the tissues. In these cases, also, surgeons 
have proposed to secure the fragments in apposition by metallic liga- 
tures or sutures. In a few instances the practice has been attended 
with success, but in most cases the wires have failed utterly of their 
purpose, and have only proved sources of additional irritation. 

Ruptured arteries, if within reach, ought always to be tied ; and if 
arteries situated remote from the surface bleed freely and for a long 
time, we may make some effort to find the open mouths in the wound; 
but in this we rarely succeed, nor is it safe generally to trust to a liga- 
ture of the main branch which supplies the limb. Fortunately, this 
bleeding, although at first profuse, generally ceases in a few hours 
under the steady employment of cold lotions, moderate compression, 
and rest. If it does not, the chances are that the case will call for am- 
putation. 

The rule generally laid down by surgeons, that we should at once 
close the wound in compound fractures, with sutures and adhesive 
straps if necessary, or with bandages, is far too absolute. This prac- 
tice will do when there is no great contusion or extravasation of blood ; 
but if blood is flowing, it is much better to leave the wound open, so 
as to permit it to escape freely; and if the severity of the injury war- 
rants the supposition that much inflammation is to ensue, the danger 
of gangrene is greatly lessened by thus allowing the opening to remain 
as a channel of exit for the inflammatory effusions. 

It has, however, been claimed of late by Mr. Lister, of Edinburgh, 
and by many others who have adopted his practice, that by the use 
of carbolic acid in the manner which will presently be described, we 
may again return safely to the old practice of closing at once all wounds 
connected with fractures, without regard to the degree of contusion, 
laceration, or comminution ; indeed, it is affirmed that by the adoption 
of this method of treatment we may avoid suppuration and its conse- 
quences in a very large proportion of cases. It is believed by Mr. Lis- 
ter that suppuration is mainly due to the presence of certain germs 
which constantly float in the air, and which carbolic acid is fully able 
to destroy. Every possible precaution is therefore taken to exclude 
the air, and to disinfect that which is unavoidably brought in contact 
with the wound. The interior of the fresh wound is fully injected with 
carbolic acid of the strength of one part of carbolic acid to twenty of 
water ; nor does he hesitate to throw this into wounds communicating 
with joints. The fluid being afterwards carefully expressed, the sur- 
face of the wound is covered first by the " protective," which is apiece 
of oiled silk coated with a thin layer of a mixture composed of one 
part of dextrin, two of powdered starch, and sixteen of a cold solution 
of carbolic acid; the latter being of the same strength as the solution 
employed for injecting the wound. Over this Mr. Lister's lac plaster 
is applied, surrounding the entire limb and extending several inches 
above and below the wound. Dr. A. R. Strachan, of this city, who 



DELAYED AND NON-UNION OF BEOKEN BONES. 63 

has been kind enough to famish me with these details, taken from his 
own notes as they were made under Mr. Lister's instructions, is unable 
to give me the formula for the lac plaster. At Bellevue we use a lac 
composed of gum shellac three parts, and carbolic acid crystals one 
part ; the shellac being stirred in gradually while the crystals are heated 
nearly to the boiling-point. 

The subsequent dressings must be made as often as the character 
and amount of the discharge may seem to require ; but at each dress- 
ing care must be taken not to admit the air to the surface of the wound ; 
and for this purpose Mr. Lister conducts the changes in the dressings 
under a stream of the watery solution of the carbolic acid, which is 
continually playing upon the part. 

Many years since, Dr. J. Rhea Barton introduced into the Pennsyl- 
vania Hospital what has since been called the "bran dressing " for the 
treatment of compound fractures of the leg ; the limb being made to 
repose in a box filled with this material. 1 I have used it very fre- 
quently in Bellevue and in other hospitals, and can speak of it as pos- 
sessing many qualities of excellence, especially as a summer dressing. 
The particular mode of using this apparatus I shall describe more 
minutely when treating of fractures of the leg. 

The treatment of inflammatory symptoms, and of the later accidents, 
such as suppuration, oedema, gangrene, tetanus, etc., must be left mainly 
to the good judgment of the surgeon. Gentle manipulation, uniform 
support, rest, and sometimes cooling lotions constitute the most impor- 
tant means by which inflammation is to be controlled. Bleeding is 
rarely necessary, and in a large majority of cases it might prove inju- 
rious by lowering too much the vital forces, which need to be hus- 
banded in view of the requirements of the process of repair and of the 
long and exhausting confinement. Cathartics should also be admin- 
istered cautiously for the same reason, and because they are liable, 
especially in fractures of the lower extremities, to occasion a serious 
disturbance of the limb. 



CHAPTER VI. 

DELAYED UNION, FIBROUS UNION, AND NON-UNION OF 
BROKEN BONES. 2 

Most surgical writers concur in the statement that non-union of 
broken bones is an uncommon event. Walker, of Oxford, affirms 

1 Paper on Bran Dressing, by Reynell Coates, of Philadelphia. Amer. Journ. 
Med. Sci., April, 1842, p. 515; from the Med. Examiner, Nos. 9 and 11, vol. i, 
New Series. 

2 I shall in this chapter avail myself freely of the labors of George "W. Norris, of 
Philadelphia, whose paper, entitled " On the Occurrence of Non-union after Frac- 
tures, its Causes and Treatment," published in the American Journal of the Medi- 
cal Sciences for Jan. 1842, constitutes the most complete and reliable monograph 
upon this subject contained in any language. 



64 



DELAYED AND NON-UNION OF BROKEN BONES. 



that of not less than one thousand fractures which have come under 
his treatment at some period of the repair, he does not recollect more 
than six or eight instances. According to Lonsdale, not more than 
five or six cases of false joint, excepting those within a capsule, have 
occurred out of nearly four thousand fractures treated at the Middle- 
sex Hospital. In a table of 367 cases, collected and arranged by W. 
W. Morland, from the books of the Massachusetts General Hospital, 
extending through a period of nineteen years, only one example of 
false joint is recorded ; but as only seventy-four days had elapsed 
when this patient was discharged, it is doubtful whether this might 
not have proved to be a case of delayed union simply. 1 In 946 cases 
of recent fracture treated in the Pennsylvania Hospital, between the 
years 1830 and 1840, there was no instance of false union. 2 Sir Ste- 
phen Hammick, Mr. Liston, and Malgaigne affirm also the infrequency 
of these accidents in the cases which have come under their personal 
treatment. I have myself seen a large number of examples of non- 
union, but in not one of my own patients, whether in hospital or pri- 
vate practice, except, in cases involving joints, has the bone refused 
finally to unite; and my opinion is, that, in proportion to the number 
of fractures everywhere, these cases are very rare, perhaps not in a 
larger proportion than one in five hundred. 

The humerus and femur would appear to be the bones most liable 
to non-union, as shown by Norris's statistics; in which forty-eight be- 
longed to the humerus, forty-eight to the femur, thirty-three to the leg, 
nineteen to the forearm, and two to the jaw. In my own experience, 
I have found the humerus ununited much more often than the femur. 

Berard has shown that in the growth of the long bones the period 
at which the epiphyses are united to the diaphyses depends upon the 
direction of the nutritive artery; for example, "It is found that in the 
humerus, where the direction of this vessel is from above downwards, 
consolidation takes place soonest at its inferior extremity. In the fore- 
arm, the course of the nutrient vessels is from below upwards, and 
here consolidation of the epiphyses is found to occur at the elbow 
sooner than at the wrist. In the inferior members, on the contrary, 
the epiphyses composing the knee are the last which become firm, 
because in the femur the nutritious artery runs upwards, and in the 
bones of the leg it courses from above downwards." A knowledge of 
these facts led Gueretin to inquire into the influence of these arteries 
upon the consolidation of fractures; and the cases collected by him 
did indeed seem to show a positive relation between the direction of 
the artery and the union of the bone ; that is to say, the examples of 
non-union were chiefly found where the fracture had taken place on 
that side of the nutritious foramen from which the artery entered, as 
if to imply that the non-union was in some measure due to the imper- 
fect nutrition of this extremity of the bone. In thirty-five cases of 
non-union analyzed by Gueretin, ten belonged to that portion of the 



1 Address on Fractures, by A. L. Pierson, read before the Massachusetts Med. 
Soc, May 27, 1840. 

2 Norris, loc. cit. 



DELAYED AND NON-UNION OF BROKEN BONES. 65 

bone which was traversed by the artery, and twenty-five to the other 
portion. But an analysis of forty-one cases, made by Norris, does not 
seem to confirm this observation of Gueretin, since twenty-seven were 
in the direction of the nutritious arteries, and only fourteen in the 
opposite portion, or in that which is supposed to be less nourished. 

Another observation, made by Curling, that in fractures of the long 
bones the portion below the entrance of the nutrient artery, or on that 
side of the nutrient foramen toward which the blood flows, being 
defrauded of its proper supply, is subjected to a species of atrophy, pre- 
senting a larger medullary canal, with thinner walls, and a spongy 
tissue less dense, also needs confirmation. Malgaigne has not noticed 
this fact in any of the specimens contained in the public museums of 
Paris ; and we do not know that any other writer has made the ques- 
tion a subject of especial inquiry. 

According to Norris, there are four principal kinds of false joint : 

In the first, the bones are united and completely enveloped in a car- 
tilaginous mass or callous tumor, but, in consequence of some retarda- 
tion in the process, bony matter is not deposited, and, as a consequence, 
it wants solidity, the part continuing easily movable. This may be 
regarded as a proper example of delayed union, as distinguished from 
complete non-union, or false joint. 

In the second, there is entire want of union of any sort between the 
fragments, the ends of which seem to be diminished in size and ex- 
tremely movable beneath the integuments. The limb in these cases is 
found wasted and powerless. 

In the third and most common class, the medullary canal is oblite- 
rated in both fragments, and the ends are more or less absorbed, 
rounded, and covered, in part or in whole, with a dense tissue resem- 
bling the periosteum. A connection also exists between the opposing 
fragments in the form of strong liga- 
mentous or fibro-ligamentous bands, 
which, if of any length, are quite 
flexible, and allow of considerable 

motion at the Seat OI fracture. Clavicle united by ligamentous bands. 

In the fourth, "a dense capsule 
without opening of any kind, containing a fluid similar to synovia, and 
resembling closely the complete ligaments, is found." In these cases 
the points of the bony fragments corresponding to each other are 
rounded, smooth, and polished, in some instances eburnated, and in 
others covered with points or even thin plates of cartilage, and a mem- 
brane closely resembling the synovial of the natural articulation. It 
is in this kind of cases, Norris remarks, that the member affected may 
still be of use to the patient, the fragments being so firmly held toge- 
ther as to be displaced only upon the application of considerable force. 

The existence of these newly formed joints, or true diarthroses, has 
been called in question by Boyer, Hewson, Chelius, 1 and others ; but 

1 Malad. Chirurg., t. iii, p. 103, Paris, 1831; North Amer. Med. and Surg. 
Journ., No. ix, p. 7, 1828; Trait, de Chir., trad, par Pigne, p. 150, 1836. (Norris, 
loc. cit.) 




66 DELAYED AND NON-UNION OF BROKEN BONES. 

the observations of Sylvestre, Brodie, Beclard, Home, Howship, Otto, 
Kuhnholtz, Houston, Cooper, Langenbeck, and Breschet prove that 
such examples are occasionally found. 1 I have myself met with several 
examples. 

A case is reported as having occurred in Boston, Massachusettes, in 
which a young man, a3t. 18, broke his humerus near its middle. Before 
union had been completed it was accidentally refractured, and from this 
time the fragments showed no disposition to unite ; on the contrary, a 
gradual process of absorption took place, until at length the whole of 
the humerus disappeared ; and that, too, " without any open ulcer." 
Eighteen years later he was perfectly well, and the arm was strong and 
useful, but no portion of the bone had been reproduced. 2 

"Norris is a disciple of Dupuytren, and accepts his doctrine of the 
formation of callus, without reservation ; consequently he finds no ne- 
cessity for but one form of delayed union, namely, that which we have 
described as belonging to the first class. In all of this class he assumes 
the existence of a cartilaginous ring or ferrule ; but we think the error 
of this exclusive theory has been sufficiently shown by the observations 
of Paget and others, and we should be warranted therefore in affirming 
the existence of as many varieties of delayed union as there are varieties 
in the manner and position of the deposit of callus, even if their actual 
existence had not been repeatedly demonstrated by dissections. 

The causes of delayed union and of non-union are either constitu- 
tional or local. 

The constitutional causes are chiefly those conditions of the general 
system which manifest themselves by anaemia, debility, or some pecu- 
liar dyscrasy. 

Sanson, Beulac, Condie, 3 and many others have mentioned cases in 
which the existence of syphilis in the system has seemed to prevent 
the formation of callus ; but, on the other hand, Lagneau and Oppen- 
heim 4 incline to the opinion that syphilis exerts in this respect but 
little influence; and even Berard, who admits the pertinence of one 
case observed by Nicod, concludes, after numerous researches, that it 
has been very rarely shown to affect the formation of callus. 5 

Pregnancy and lactation have been known to interfere with the 
union of bones. Werner, Hildanus, Wilson, Hertodius, Alanson, Bard, 
of New York, and Condie, of Philadelphia, 6 have all reported examples, 

1 Nouvelles de la Repub. des Lettres de Bayle, p. 718, 1685; Lond. Med. Gaz , 
xiii, p. 57, 1833; Beclard, Gen. Anat., trans, by Hayward, pp. 149, 248; Transac. 
Med.-Chir. Soc. of Edinburgh, i, p. 233, 1793; Med.-Chir. Trans., viii, p. 517, 
1817; Otto's Path. Anat., trans, by South, i, p. 138; Journ. Complement., iii, p. 
291 ; Dub. Med. Journ , viii, p. 493 ; Cooper on Frac. and Disloc., fourth London 
ed., p. 508; Recherch. sur les Formation du Cal, 1819, p. 34. (Norris, loc. cit.) 

2 Boston Med. and Surg Journ., July 11th, 1868, p. 368. 

3 Diet, de Med. et Chir. Prat., iii, p. 492 ; Journ. de Med. Chir. et Pharm., t. xxv, 
p. 216. (Norris, loc. cit.) 

4 Expose des symp. de la mal. Ven., p. 525; Oppenheim on False Joints, 1837. 
(Norris, loc. cit.) 

5 Op. cit, p. 21. 

6 Cooper's Die, ed. 1838, p. 546: Opera Hild., 1681; Wilson on the Human 
Skeleton, p. 214; Bib. Choisie de Med., xxiv, p. 595; Med. Obs. and Inquiries, 4, 
1772; Philosoph. Trans., xlvi, p. 397, 750. (Norris, loc. cit.) 



DELAYED AND NON-UNION OF BROKEN BONES. 67 

in some of which the process of union was resumed and brought to a 
rapid completion so soon as the period of pregnancy was closed, or 
when lactation ceased ; but three cases reported by Sir Stephen Love 
Hammick would seem to show, what, indeed, other evidences render 
probable, that the delay was less due to the fact of the pregnancy and 
the lactation than to the debility occasionally consequent upon these 
conditions. 1 

As to the question whether cancer ever causes a delay in the union 
of bones, it may be said that where the fracture arises in consequence 
of a true cancerous deposit around or in the interior of the bones, j3ro- 
ducing absorption of their tissue, no union takes place ; but that the 
mere presence of the cancerous cachexy does not usually prevent the 
formation of callus. 

Scurvy, fevers of a low type, and, on the other hand, fevers of a 
highly inflammatory character, profuse uterine and vaginal discharges, 
and rachitis, conduce to the same result. 

The withdrawal of an habitual stimulus, and especially a change from 
a good to a low diet, or copious bleedings, may either of them delay 
the deposit of ossific matter, or prevent it altogether. 2 

Bonn has furnished two cases in which advanced age seemed to 
have retarded the formation of callus, but Horner saw a fracture of the 
humerus in a woman ninety years old unite in five weeks. 3 I have 
myself noticed a good many similar examples in advanced life, and 
it is now rendered quite probable that surgeons have generally over- 
estimated the influence of age upon the formation of callus. 

The local causes are, arrest of the arterial circulation by bandages; 
arrest of the venous circulation by pressure, by rupture of veins, or by 
the formation of venous clots; 4 paralysis or impairment of the nervous 
circulation ; the occurrence of the fracture within a capsule; obliquity 
of the fracture; overlapping of the fragments; interposition of a piece 
of bone, of a tendon, muscle, or of a clot of blood, or separation of the 
fragments from any cause whatever ; erysipelas ; acute phlegmonous 
inflammation; suppuration; necrosis; too much motion; exclusion of 
light and air inducing local scurvy ; wet, and especially cold and moist 
dressings ; too early use of the limb, etc. 

In order to hasten the consolidation when it is simply delayed, we 
resort to all of those expedients which are calculated to invigorate 
the general system ; and for this purpose the employment of a nutri- 
tious diet and the use of mineral or vegetable tonics may not be prop- 
erly omitted ; but in our experience nothing has proved so efficient as 
encouraging the patient to leave his bed and get out into the open air ; 
for which purpose, if the fracture is in the lower extremities, crutches 
will be necessary. 

As local means, we may enumerate first the removal of those local 
causes which seem to have interfered with the consolidation or with 
the union. If the fragments have been officiously disturbed, it may 

1 Practical Kemarks on Amputations, Fractures, etc., p. 121. (Norris, loc. cit.) 

2 Norris, loc. cit. 

3 Ibid., p. 29. 

4 George W. Callender, Brit. Med. Journ., Nov. 30, 1872. 



68 DELAYED AND NON-UNION OF BROKEN BONES. 

bo sufficient to impose upon the limb absolute rest for a certain length 
of time ; and the fragments may be more closely pressed against each 
other; in other cases it will be found necessary to remove the band- 
ages, expose the limb freely to the light and air at least once or twice 
daily, and to rub it gently with the dry hand or with some moderately 
stimulating oil, so as to induce a more healthy condition of the soft 
parts, and encourage the natural circulation. 

Moving the fragments freely upon each other, sufficient to determine 
a degree of excitement in the adjacent tissues, and upon the opposing 
surfaces of the bones, and then confining them during one or two weeks 
in firm and well-fitting splints, will sometimes succeed when other 
means have failed. 

Indeed, I may say that by one or another of the simple methods 
now enumerated I have never failed, sooner or later, to effect consolida- 
tion in recent fractures ; and it has only been in fractures of at least four, 
six, or eight months' standing that I have been compelled to resort to 
more extreme measures. 

As a means of combining immobility with compression and health- 
ful exercise, the " apparatus immobile," in many of its forms, is pecu- 
liarly adapted. White, of Manchester, employed a firm leather sheath 
for the thigh. H. H. Smith, of Philadelphia, recommends a more 
complex artificial support, upon which the limb may be allowed to 
rest while in the act of progression. 1 With some surgeons, the object 
of allowing the patieut to walk, in fractures of the thigh or leg, is chiefly 
to excite in the tissues adjacent to the seat of fracture some degree of 
inflammatory action ; but which, as the result in one of White's patients 
has sufficiently shown, may be carried too far, and even determine a 
suppuration. 

Dr. E. R. Hudson, artificial limb maker, of New York, has applied 
in similar cases, which have come under my observation, an apparatus 
of his own construction, made of willow, and secured in place by leather 
straps. In case the purpose of the apparatus is to encourage bony 
union, no motion is allowed at the knee-joint. 

Blisters, mustard cataplasms, the tincture of iodine, 2 caustics, 3 etc., 
applied externally over the seat of fracture, can have no other effect 
than to increase moderately the congestion of the tissues, and in so far 
they may aid in the accomplishment of the bony union ; but in this 
respect they are inferior to the violent twistings, flexions, and rubbings 
of the broken ends of which we have already spoken. 

Electricity was first employed by Mr. Birch, of London, but Dr. 
Valentine Mott obtained no effect from it in two cases where he seems 
to have given it a fair trial. 4 Lente, of the New York Hospital, has 
furnished an account of three cases treated in that institution by elec- 
tricity in connection with acupuncturation ; the mode of using which 
Avas to pass a needle down to the periosteum on each side of the bone, 
and to attach the poles of the battery to these opposite points. Lente 

1 H. H. Smith, Arner. Journ. Med. Sci., Jan 1855. 

2 Hartshorne, Eclectic Rep., vol. iii, p. 114, 1813. 

3 Willoughby, Am. Journ. Med. Sci., Aug. 1834, p. 444. 

4 Mott, Med. and Surg. Rep., p. 21, p. 375. 



DELAYED AND NON-UNION OF BROKEN BONES. 69 

thinks that electricity employed in this way is much more efficient 
than when the poles are merely applied to the surface. He informs us 
also that other cases than these now reported have been treated suc- 
cessfully in this hospital by means of electricity. 1 

Mercury will no doubt prove serviceable occasionally by virtue of 
its powers as an anti-syphilitic, but its beneficial influence in other 
cases is far from having been established. 

The seton is said to have been first suggested by Winslow, in 1787; 
but, what is of much more consequence, the credit of its first successful 



Fig. 17. 



Fig. 18. 





Hudson's splint for ununited fractures of femur, 
accompanied with shortening of the limb. 



Physick's first case, after 28 years. 
(From Am. Journ. Med. Sci.) 



application and its general introduction into practice is due to Dr. 
Philip Syng Physick, of Philadelphia, by whom it was employed in 
1802. 2 

Physick used for his seton, generally, silk ribbon, or French tape; 
and this he introduced by means of a long seton needle, between the 
ends of the fragments. He recommended that the seton should remain 
in place four or five months, and longer if necessary, and it was his 
opinion that the failures were generally due to its being removed too 



1 Lente, New York Journ. Med., Nov. 1850, p. 317. 

2 Physick, Med. Kepository of New York, vol. i, 1804. 



70 DELAYED AND NON-UNION OF BROKEN BONES. 



Fig 




early. At the present day, however, surgeons who employ the seton 
think it serves its purpose better when it remains in place but a few 
clays, not longer, perhaps, than ten or fifteen, always taking care that 
it' is removed before excessive suppuration is induced. It has been 
found especially valuable in fractures of the inferior maxilla, clavicle, 
and of the upper extremities; but in the case of the femur, it has so 
frequently failed, that Dr. Physick himself did not recommend its use. 
In case the seton cannot be passed directly between the opposing 
fragments, as recommended by Physick, we may adopt the practice 
suggested by Oppenheim, and carry two setons, one on each side, close 
to the bone. 

Somme, of Antwerp, preferred a loop of wire to the silk seton em- 
ployed by Physick. 1 Seerig passed a ligature around the ligamentous 
mass connecting the two fragments, and then 
proceeded to tighten the ligature until it fell off. 2 
Dr. Hulse, of the U. S. Navy, employed stimu- 
lating injections with success in a case of non- 
union, accompanied with an external and fistulous 
opening. 3 In 1848, Dieffenbach recommended 
that ivory pegs be introduced into holes previ- 
ously made in the bone, 4 by means of a gimlet or 
drill, and Mr. Stanley has succeeded once by this 
method. 5 Mr. Hill introduced the ivory pegs in 
a case of ununited fracture of the femur, pyaemia 
supervened, and the patient died. 6 

Malgaigne, in 1837, tried to introduce acu- 
puncture needles between the ends of an united 
fracture, but although he thrust the needle down 
to the bone thirty-six times, he was unable to 
make it pass once between the ends of the frag- 
ments. 7 Wiesel succeeded better. In a case of 
ununited fracture of the ulna, of nine weeks' 
standing, having passed two needles between the fragments, at the end 
of six days, the needles being removed, consolidation rapidly ensued. 8 
This practice does not differ essentially from the metallic loop of Somme. 
It is only a modification of the seton. 

Brainard, of Chicago, has attempted to show that setons of any 
kind, whether of wood, ivory, or metal, placed in contact with the 
bone, occasion absorption, caries, and necrosis, but that they never di- 
rectly give rise to bony callus; and that the occasional success of the 
seton, which success he believes to have been greatly exaggerated, has 
not resulted from any tendency to favor the formation of callus, but 



Dieffenbach's drills for un 
united fracture. 



1 Araer. Journ. Med. Sci , vol. vii, p. 497. 

2 Norris, loc. cit., p. 46. 

3 Hulse, Amer. Journ. Med. Sci., vol. xiii, p. 374. 

4 Malgaigne, trans, by Packard, op. cit., p. 258, note. 

5 Stanley, New York Journ. Med., Nov. 1854. p. 441, from Dublin Press. 

6 New York Med. Gaz., July 4, 1868, from the London Lancet. 

7 Malgaigne, op. cit. 

8 Wiesel, Amer. Journ. Med. Sci., vol. xxxiv, p. 254, July, 1844. 



DELAYED AND NON-UNION OF BROKEN BONES. 71 

from the induration and tenderness of the soft parts produced by it; 
circumstances which, by conducing to rest, indirectly favor the consoli- 
dation. 1 

In May, 1848, Miller, of Edinburgh, reported five cases treated 
successfully by subcutaneous puncture. The operation consisted in 
passing the point of a needle or small tenotomy bistoury down upon 
the ends of the bone, and freely irritating the surfaces at several points. 2 
George F. Sandford, of Davenport, Iowa, has successfully imitated 
this practice in two cases. 3 

In 1850, Dr. William Detmold, of New York, performed the ope- 
ration of drilling or perforating the fragments in a case of ununited 
fracture of the tibia, employing for this purpose a large gimlet. He 
first bored two holes between the opposing fragments, and then, intro- 
ducing the gimlet one and a half inch below the fracture, he penetrated 
the tibia upwards and inwards until he had traversed, also, the upper 
fragment to the extent of an inch. In three weeks the bone appeared 
firm, but from this time the patient was not seen. 4 

Brainard employs for this same purpose a strong metallic perforator, 
consisting of a handle, into which points of different sizes may be in- 
serted, and which have been hardened so as to penetrate the hardest 
bone or even ivory in every direction easily. The points are " some- 
what awl-shaped ; but more pointed in the middle rather than like a 
drill, which leaves chips." His manner of using this instrument is as 
follows : " In case of an oblique fracture, or one with overlapping, the 
skin is perforated with the instrument at such a point as to enable it 

Fig. 20. 




Brainard's perforator, reduced one-half. 

to be carried through the ends of the fragments, to wound their sur- 
faces, and to transfix whatever tissue may be placed between them. 
After having transfixed them in one direction, it is withdrawn from 
the bone, but not from the skin, its direction changed, and another 
perforation made, and this operation is repeated as often as may be de- 
sired." Dr. Brainard, who succeeded by this procedure in a number of 
cases of ununited fracture, thinks it is better to commence in most cases 
with not more than two or three perforations, in order that the effect 
produced shall not be too severe. It is scarcely necessary to add that, 
after the punctures have been made, the limb should be put completely 
at rest in appropriate splints, or in apparatus of some kind. 

Mr. Tieman has made for me a bone-drill which is rotated by the 

1 Brainard, Trans. Amer. Med. Assoc, vol. vii, 1854: Prize Essay. Eeport on 
Surgery to Illinois State Med. Soc., May, 1860. 

2 Miller, New York Journ. Med., July, 1848, p. 134. 

3 Sandford, Trans.' Amer. Med. Assoc., vol. iii, p. 355, 1850. 

4 New York Med. Gazette, Oct. 12, 1850. 



72 DELAYED AND NON-UNION OF BBOKEN BONES. 

movement of a handle upon a rod or shaft composed of twisted wire, 
and which possesses the advantage of being worked with great facility 
and rapidity. Perforators of any size or shape may be fitted to the 

Fig. 21. 

m 




The author's bone-drill. 

shaft at pleasure. In most cases I have found Brainard's drill a better 
instrument than my own. 

Scraping or rasping the ends of the bones is a practice which dates 
from a very early period. Mr. Brodie scraped the ends of the bones, 
and then interposed a bit of lint. 1 Mayor, in 1828, contrived to in- 
troduce an iron, previously heated in boiling water, through a canula, 
and thus brought the heat to bear directly upon the ends of the frag- 
ments ; and by repeating the application several times, a cure was 
effected. 2 

Resection of the ends of the bones, first brought into notice by 
White, of Manchester, in 1760, 3 and opposed by Brodie 4 as dangerous, 
and by Malgaigne regarded as generally useless or unnecessary, has 
still been practiced a great number of times, with more or less success. 
It is especially applicable to superficial bones, and in cases where the 
bones overlap. 

Roux practiced resection in one instance, and then managed to en- 
gage the point of one of the fragments in the medullary canal of the 
other. 5 I have succeeded in doing the same. 

White, of Manchester, Henry Cline, of London, Hewson, Barton, 
and Norris, of Philadelphia, have applied caustics directly to the ends 
of the fragments, after having exposed them by a free incision. 6 Petit 
applied the actual cautery. 7 

Tying the fragments together by means of metallic ligatures after 
a recent fracture, is as old as the days of Hippocrates; but in 1805 
Horeau adopted the same procedure in a case of ununited fracture. 8 
Since which date it has been practiced successfully by many surgeons. 
My own experience confirms the value of the method, especially when 
the fragments overlap. 

1 Brodie, Lond. Med. Gaz., July, 1834. 2 Norris, loc. cit., p. 48. 

3 Diet, de Med., vol. xxiii, p. 503. 

4 Brodie, New York Journ., vol. viii, 1st ser., p. 133. 

6 Norris, loc. cit., p. 49. 6 Ibid. 7 Ibid. s Ibid. 



DELAYED AND NON-UNION OF BROKEN BONES. 73 

E. S. Gaillard, of Louisville, Ky., proposes to secure the fragments 
in place by means of a metallic pin. The instrument which he em- 
ploys is composed of a steel shaft with a handle, a silver sheath, and a 
brass nut. For a broken femur, the shaft is six inches long, its lower 
extremity being constructed like a gimlet, while two and a half inches 
of its upper extremity are cut for a male screw, being intended to 
carry the brass nut. The sheath is three inches loug. 

Through an incision made over the seat of fracture, the sheath, de- 
tached from the shaft, is carried down to the bone. The shaft is then 
passed through the sheath, and made to penetrate and transfix the two 
fragments; as soon as this is accomplished, the nut is turned down 

Fig. 22. 




Gaillard's instrument for ununited fractures. 

firmly upon the top of the sheath, and apposition of the fragments is 
thus secured. The whole instrument is permitted to remain until bony 
union is effected. 1 

Finally, having thus brought rapidly before us all of the various 
modes of treatment which have been suggested and practiced for non- 
union of broken bones, we are prepared to affirm the following con- 
clusions, or summary of what has been our own practice, and of what 
we believe ought to be the general course of procedure in these cases : 

First. Improve the condition of the general system. 

Second. Remove as far as possible the local impediments, such as 
a separation of the fragments, local paralysis, local scurvy resulting 
from long exclusion from light and air, congestions, etc. 

Third. Increase the action of the tissues immediately adjacent to the 
fracture, upon which tissues, rather than upon the bone, as Malgaigne 
thinks, the formation of callus depends. A theory which, as applied to 
old and ununited fractures, we are not prepared to deny. This may be 
accomplished by frictions, and violent flexions of the limb at the seat 
of fracture ; possibly in some measure by the application of vesicants 
or of other stimulants to the skin itself. 

Fourth. Employ again compression and rest for a period of from 
two to four or eight weeks. 

Fifth. Resort to the method recommended by Brainard. 

Sixth. If in the lower extremity, allow the patient to walk about 
with the fragments well supported. 

Seventh. If the fracture is not in the femur, and as an extreme 
measure, employ the seton, or resection. 

1 E. S. Gaillard, New York Journ. Med , Nov. 1865. 
6 



74 BENDING, PARTIAL FRACTURES, AND FISSURES. 

Where these measures have failed, after a fair trial, we should either 
abandon the case as hopeless, only supporting the limb by such appa- 
ratus as may be found most serviceable, or we should recommend 
amputation. 



CHAPTEE VII. 

INCOMPLETE FRACTURES. 
BENDING, PARTIAL FRACTURES, AND FISSURES OF THE LONG BONES. 

I 1. Bending of the Long Bones. 

Strictly speaking, no bone can be much bent without being also 
more or less broken, and that whether it immediately and sponta- 
neously resumes its position or not ; for, if the bending and straighten- 
ing of the bone be repeated a sufficient number of times, the yielding 
of the fibres will become apparent, and at length the separation will be 
complete. The first of this series of flexions was quite as much respon- 
sible for this result as the last, and, no doubt, performed its share in 
the production of the complete fracture. 

There could be no impropriety, therefore, in speaking of a bending 
of the bones as a variety of incomplete fractures, as I have done in the 
first section of my u Report on Deformities after Fractures," made to 
the American Medical Association in 1855. 1 

They have been called, not inappropriately, interperiosteal fractures, 
since in these cases the periosteum is not broken ; M. Blandin thinks 
that the outer and semicartilaginous laminae of the bone also do not 
break, while the deeper laminae suffer an actual disruption. 2 But it is 
quite as probable that in a majority of cases the true pathological con- 
dition is a compression of the bony fibres upon one side, with a cor- 
responding expansion upon the opposite side, with only a slight inter- 
stitial fracture, too trivial to be easily recognized even in the dissection. 
Sometimes, as I have several times observed in my experiments on the 
bones of chickens, when the bones are small, and the bending is near 
the centre of the shaft, the whole of the laminae on the side of the retir- 
ing angle produced by the bending are doubled in, or indented toward 
the hollow of the bone, so that the fibres on the side of the salient 
angle are not even stretched, and much less broken. In such cases, 
the interstitial disruption, if it exists at all, and I think it does, first 
takes place in the deeper layers of the retiring angle. 

I might, therefore, feel justified in continuing to call these cases par- 
tial fractures, or, perhaps, interstitial fractures, but I believe that the 
whole subject will be rendered more intelligible if I call them simply 

1 Op. cit., pp. 411-422. 

2 Markham's Obs. on the Surg. Practice of Paris, London Med.-Chir. Rev., vol. 
xxxiv, p. 473, 1841. 



BENDING OF THE LONG BONES. 75 

bending of the bones, as distinguished from those other and more pal- 
pably partial fractures of which I shall speak presently. 

1. Bending with an immediate and spontaneous restoration of the bone 
to its original form. — The possibility of this accident, to which, how- 
ever, surgical writers have hitherto made no distinct allusion, is ren- 
dered certain by the following experiments : 

Experiment 1. — July 16, 1857. I bent the tibia of a Shanghai 
chicken, four weeks old, at about the middle of the bone. It was bent 
to an angle of quite twenty-five degrees, but it was not felt or heard 
to break. It immediately and spontaneously resumed the straight po- 
sition. 

July 18, two days after the bending, I dissected the limb, and found 
no trace of the injury, either within or without the bone, unless I ex- 
cept a very minute blood-clot in the centre of the shaft. 

Experiment 2. — I bent the leg of a chicken, four weeks old, at the 
same point and to the same degree. It immediately resumed the 
straight position. 

Dissection after two days. Nothing abnormal except a small blood- 
clot in the centre of the bone, and a slight disorganization of the 
medulla. 

Experiments 3 and 4. — Bent both legs of a chicken, four weeks old, 
at the same point and in the same manner. They immediately re- 
sumed their positions. 

Dissection after two days. No lesions or morbid appearances which 
I could detect. 

Experiments 5 and 6. — Bent both wings of a chicken four weeks old. 
Bent the right wing to an angle of thirty-five degrees. I did not feel 
them break. Both resumed their positions spontaneously. 

Dissection after two days. No lesions or other morbid appearances. 

Experiment 7. — July 16, 1857, 1 bent the leg of a Shanghai chicken, 
five weeks old, below the knee and about the middle of the bone. It 
was bent to an angle of about twenty -five degrees, but the bone was 
not felt or heard to break. It immediately and spontaneously resumed 
the straight position. 

July 20, four days after the bending, I dissected the leg, but could 
not discover any trace of the injury, except that there was a very mi- 
nute ossific deposit in the centre of the bone at the point at which I 
suppose it to have been bent. 

Experiment 8. — July 16, 1857, I bent the right leg of a Shanghai 
chicken, five weeks old, at the same point as in the first experiment, 
and to the same extent. The bone did not seem to break, but it im- 
mediately and spontaneously resumed the straight position. 

Dissection after four days. Nothing appeared to indicate the seat of 
the bending except a small clot of blood in the centre of the shaft. 

Experiment 9. — Bent the leg of a chicken, six weeks old, in the 
same manner and to the same degree as in the other examples. It re- 
sumed its position spontaneously. 

Dissection after ten days. No evidence of injury of any kind ; the- 
bone being sound and straight. 

These experiments were made in connection with others to which 



76 BENDING, PARTIAL FRACTURES, AND FISSURES. 

more especial reference will hereafter be made. They are selected, and 
constitute the whole number of those in which I did not feel the bone 
break or crack under my fingers. In every instance the bone sprung 
back immediately and spontaneously to its natural form. In no in- 
stance could I afterward discover any trace of lesion or sign indicating 
the point at which the bone had been bent before dissection, nor did 
dissection itself disclose anything but the most inconsiderable marks, 
and that in but three examples. 

I infer, therefore, not forgetting the caution with which the conclu- 
sions from all such experiments ought to be applied to similar accidents 
upon the human skeleton, that whenever the bones of healthy infants 
have been slightly bent and not broken, they will, probably, in most 
cases, unless prevented by causes foreign to the bones themselves, spon- 
taneously and immediately resume their position, and that no sign will 
remain to indicate that a bending has occurred. The accident will not 
be recognized, and, as a farther inference, this bending does not belong 
to that class of cases of which I shall next speak. 

2. Bending without immediate and spontaneous restoration of the bone 
to its original form. — " Dethleef, believing that he had broken the two 
bones of the leg of a dog, found the fibula bent without a fracture. 
Similar results were obtained by Duhamel upon a lamb ; by Troja 
upon a pigeon ; and I have myself twice succeeded in bending the 
fibula while breaking the tibia. The possibility of simple curvature 
is then not contestable" (the writer means to say that the possibility 
of a simple curvature remaining permanently bent is not contestable), 
u but we must observe that they have never been obtained except upon 
young animals, and that they have been unable to maintain themselves 
permanently except through the aid of a fracture and displacement of 
a neighboring bone ; and there is a wide difference between these and 
those pretended curvatures which some believe they have seen in man, 
in which the curved bone maintains itself, and resists perfect reduction 
until the fracture is complete." 1 

In this single paragraph Malgaigne seems to have given a fair sum- 
mary of the testimony upon this point. With the exception of these 
and a few other similar examples, some of which I think I have ob- 
served myself, where one of the bones of the forearm has been broken 
and the other bent, I know of no well-attested cases of a permanent 
bending; using the term bending in a sense distinguished from a par- 
tial fracture. 

If, in numerous cases mentioned by surgical writers, there has seemed 
to be probable evidence that the permanent bending was unaccompanied 
with fracture, there has always been wanting, so far as I know, the posi- 
tive evidence of dissection. The example of partial fracture mentioned 
by Fergusson, and represented by a drawing, is described as having 
also, "toward the lower extremity, a slight indentation and curve." 2 
This was the radius of a child; but how long the child survived the 

1 Traits des Frac, etc., par L. F. Malgaigne, torn, i, p. 48. 

2 Practical Surgery, by William Fergusson, 4th Am. ed., p. 208. 



BENDING OF THE LONG BONES. 



77 



Fig. 23. 




Case mentioned by 
Fergusson. 



accident, and what was the condition of the ulna, we are not informed. 
The observations made by Jurine, of Geneva, in Switzerland/ by 
Barton 2 and Norris, 3 of Philadelphia, all fail to furnish 
any such conclusive evidence of the correctness of their 
own views. Norris says that " Thierry, of Bordeaux, 
Martin, and Chevalier, had all met with and published 
cases of this kind prior to the appearance of Jurine's 
paper (in 1810), the former of whom asserts that Haller, 
in experimenting upon the subject, had been able satis- 
factorily to produce the same accident in young ani- 
mals." For myself, I cannot say how much confidence 
we ought to place in these assertions of Thierry, Martin, 
and Chevalier, having never seen the papers referred 
to ; but since Dr. Norris has neglected to inform us 
whether any dissections were ever made, we shall not 
be expected to regard their testimony as conclusive. 

With the qualifications now made, Gibson was more 
nearly right when he said, " Dupuytren and Dr. John 
Rhea Barton have each furnished accounts of bent bones. 
There are no such injuries, however, in my opinion; 
such cases being, in reality, partial fractures from which 
deformities result upon the same principle that a piece of tough wood, 
like oak or hickory, if broken half through, may be inclined to one 
side and shortened, although still held together by interlocking of 
fibres. Many specimens in my cabinet, and in the Wistar Museum, 
attest the accuracy of this assertion." 4 

In my own experiments upon the chicken, the bones uniformly re- 
sumed their original position as soon as the restraining force was 
removed, unless a fracture occurred, and this notwithstanding the 
bones were bent quite abruptly and to an angle of twenty-five degrees. 
Certainly, if the bones of children may be bent during life and be 
made to retain this position without a fracture, then the same thing 
might be done upon the bones of children recently dead, and, by suc- 
cessful experiments, this long-agitated question might be easily and 
forever put to rest. 

It will be understood that our observations are confined to the long 
bones. That the flat bones, and especially the bones of the cranium, 
in childhood, may be indented by blows, and remain in this condition, 
is undeniable. Scultetus says he had seen " the skull pressed down in 
children, without a fracture, so that those who touch or look upon it 
can perceive a small pit," 5 and it has been mentioned by many writers 
since, and perhaps before his day. I have myself published two ex- 
amples of it in the second volume of the Buffalo Jledical Journal, 6 and 
since the date of that publication I have met with others. 



1 Journ. de Corvisart et Boyer, torn, xx, p. 278, etc. 

2 Phila. Med. Recorder, 1821. 
vol. xxix, p. 233, 1842. 



3 Phila. Med. Journ., 

4 Institutes and Practice of Surgery, by "VVm. Gibson, Phila.. 1841, vol. l, 

5 The Chirurgeon's Storehouse, by Johannes Scultetus, 1674, p. 126. 

6 Op. cit , p. 347, 1846, Cases 1 and 2. 



p. 254. 



78 BENDING, PARTIAL FRACTURES, AND FISSURES. 



2 2. Partial Fracture of the Long Bones. 

1. Partial Fracture with Immediate and Spontaneous Restoration of 
the Bone to its Original Form. — No writer seems to have given any- 
special attention to the form of fracture now under consideration, al- 
though its existence appears to have been occasionally recognized. In 
the case reported by Camper, in 1765, of a partial fracture of the tibia, 
the bone had regained its natural form, but whether immediately after 
the accident occurred, or at a later period, I am not able to learn. 1 
Jurine, Gulliver, and others, have noticed a gradual straightening of 
the bone after a partial fracture, so that its complete restoration has 
been accomplished after several weeks or months ; but this, although 
partly due to the same cause which produces occasionally an immediate 
restoration, namely, its elasticity, is in part also due to other causes, 
and will be more properly considered under the next division of partial 
fractures. 

Says Malgaigne : " Finally, at other times the fracture takes place 
without opening and without curvature ; the only sign which one can 
recognize is a yielding of the bone under the pressure of the ringer, 
at the point of fracture ; yet upon the living subject we may see the 
same symptom pertain to complete and simple fractures without dis- 
placement." 2 

In the following report of one of M. Blandin's clinics the accident 
is described a little more distinctly : "In some cases of fracture of the 
clavicle occurring about the middle of the bone in young subjects, dis- 
placement of the fragments does not immediately take place, thus giving 
rise to a risk of an error in diagnosis, by which the ultimate probability 
of a cure is diminished. A lad seventeen years of age was recently 
admitted into the Hotel Dieu, under the care of M. Blandin, having, 
a few days previously, fallen upon one of his comrades while playing 
with him, when he instantly experienced pain and a cracking sensation 
about the middle of the left clavicle, where there soon formed a tumor, 
which increasing, induced him to enter the hospital. On examination, 
the swelling was found to occupy the middle of the clavicle ; it was 
about as large as half a hen's egg, ovoid in shape, well circumscribed, 
colorless, and hard, but sensible to pressure. There was not any de- 
formity of the shoulder, nor any abnormal modification of the axis of 
the bone, to indicate the existence of a fracture; and although the dif- 
ferent movements of the arm caused pain in the shoulder, yet they could 
be made without much difficulty. 

"The symptoms in this case would lead to the belief that it was a 
case of simple periostitis, caused by external violence; but M. Blandin 
at once decided that there existed a fracture of the bone, having seen 
a similar case previously at the hospital Beaujon, where the tumor was 
treated as traumatic periostitis, the patient merely carrying his arm in 
a sling, until, by a sudden movement of the limb, displacement of the 
fragments was produced, and clearly demonstrated the existence of a 

1 Essays and Obs. Phys. and Lit. of Soc. of Edinburgh, vol. iii, p. 527. 

2 Op. cit, torn, i, p. 50. 



PAETIAL FRACTURE OF THE LOXG BOXES. 79 

fracture. A second case occurring soon afterward, M. Blandin profited 
by the experience gained from the preceding, and by moving the frag- 
ments of the broken clavicle on each other, obtained motion and crepi- 
tus. Still these indications were not so clear, that M. Marjolin could 
diagnosticate a fracture ; he was of opinion that the case was one of ex- 
ostosis, probably syphilitic, and the crepitus, he believed, depended on 
an erosion of the osseous surface. In consequence, the patient was left 
to himself, until a movement of the arm gave proof of the fracture by 
the displacement of the broken portions of the bones. 

"Two other cases occurring in young subjects have been admitted 
since in the Hotel Dieu, under the care of M. Blandin, one of whom 
was purposely left without surgical assistance, while Desault's bandage 
was applied to the other. The former soon showed evidence of con- 
secutive displacement; the latter was cured without any deformity fol- 
lowing. 

" The surgeon may diagnose a fracture, without displacement of the 
middle portion of the clavicle, when a circumscribed tumor forms in 
that part of young subjects, consecutive on a fall on the shoulder, and 
motion of the fragments, with crepitus, can be detected, there not being 
any syphilitic taint in the constitution." 1 

The following examples, which have come under my own observa- 
tion, will illustrate more completely the usual history and symptoms 
of these cases : 

A. B., aged three years, fell from the sofa upon the floor, striking, 
it is thought, on her right shoulder. Two days after this, she fell 
again, and then for the first time, Mr. B. noticed the deformity. She 
was brought to me three days after the second fall. There existed 
then a round, smooth projection at the outer end of the middle third 
of the clavicle. It felt hard, like bone. The line of the clavicle was 
not changed. I advised a handkerchief sling, simply to steady and 
support the arm. Seven months after the accident, she fell sick and 
died. The projection continued at the time of death, only slightly 
diminished. 

H. S., aged six years, was thrown from a horse, partially breaking 
his left clavicle, near its middle. Dr. Sprague, of Buffalo, was em- 
ployed. The projection in front was for several days very apparent, and 
was examined by myself at Dr. Sprague's request. The bone did not 
seem to be out of line. Five years after the accident, I examined the 
lad, and could not find any trace of the original injury. 

September 25, 1855. Mrs. T. C. brought to me her infant child, 
then but two weeks old. Upon the left clavicle, at a point a little 
nearer the acromion process than the sternum, was an oblong swelling, 
three-quarters of an inch in length, smooth and hard like callus ; the 
skin was not reddened, nor tender. There was no motion or crepitus, 
and the line of the axis of the bone was perfect. The mother, who had 
been put to bed by a midwife, thinks the injury occurred in the act of 
birth, although she did not notice the swelling until a week after. 

1 Am. Journ. Med. Sci., vol. xxxi, p. 473, from Journ de Med. et Chirurg. Frat, , 
July, 1842. 



80 BENDING, PARTIAL FRACTURES, AND FISSURES. 

October 20. Nearly one month later, I found no change in the con- 
dition of the bone ; the hard lump remained, but it was still entirely 
free from tenderness. I have not seen the child since. 

An infant boy, three years old, fell, August 12, 1857, from the 
hands of the nurse. The child cried, but the point of injury was not 
detected until the third or fourth day, although the mother examined 
the shoulders and neck carefully at the time. She is quite certain 
that if any swelling or discoloration had been present, she would have 
seen it then, or on the subsequent days, while washing and dressing the 
child. When first seen it was very distinct, but not so large as at 
present. 

August 19. The child was brought to me. A little to the sternal 
side of the middle of the right clavicle there was an oblong node-like 
swelling, of the size of the half of a pigeon's egg, hard, smooth, and 
feeling like bone; there was no discoloration or swelling of the integu- 
ments; no crepitus or motion; the line of the clavicle seemed nearly or 
quite unchanged. 

I have not noticed this variety of accident in any other bone except 
the clavicle, vet it is not improbable that it happens occasionally, and 
perhaps quite as often, in other long bones, but that its existence is not 
elsewhere so easily recognized. 

Of one hundred and forty-two fractures of the clavicle recorded by 
me, twenty-nine were partial fractures ; and of these at least six were 
spontaneously and immediately restored to their natural axes. 

In explanation of the fact that hospital surgeons have not observed 
so large a proportion of partial fractures of the clavicle, it must be stated 
that most of these cases of partial fracture were drawn from private 
practice. Accidents of this class may be often met with in dispensaries, 
but they are seldom found in hospitals. 

Experiment. — In fourteen experiments upon the bones of chickens, 
a partial fracture, with immediate and spontaneous restoration, has 
occurred but once. In nine of these cases the bones were only bent, 
and in five they were partially broken; an immediate restoration has 
occurred, therefore, in one case out of five of partial fracture ; while in 
my reported examples of partial fracture of the clavicle it has been 
noticed about once in every three or four cases. The following is the 
experiment to which I have referred : 

I produced a partial fracture of the tibia in a chicken six weeks old. 
The fracture was near the middle of the bone. I felt it break under 
my finger ; but on removing the pressure, it immediately and spon- 
taneously resumed the straight position. 

I dissected the limb on the tenth day. The line of the axis of the 
bone was perfect ; but on the fractured side was a node-like enlarge- 
ment, sufficient to be distinctly felt and seen before the soft parts were 
removed. 

Pathology. — In no case, except in my single experiment upon the 
bone of a chicken, has the actual condition been determined by dis- 
section, and if any question has existed heretofore as to the possibility 
of an immediate and spontaneous restoration after a partial fracture, 
this experiment ought to decide it in the affirmative; but then the first 



PARTIAL FRACTURE OF THE LONG BOXES. 81 

nine experiments already quoted have shown that a mere bending with 
immediate restoration leaves no such traces or signs as have been de- 
scribed as following these accidents. We have, therefore, the negative 
argument that, since a bending with restoration leaves no signs, these 
examples, reported by myself and others as having occurred, and as 
having been followed by a node-like swelling, etc., must have been 
partial fractures. Moreover, in one of the cases of immediate restora- 
tion reported by Blandin, there was a feeble crepitus ; and in another, 
the subsequent displacement proved the correctness of his diagnosis. 

We conclude, then, that these are examples of partial fracture, but 
that the number of bony fibres which have given way are too incon- 
siderable, as compared with those not broken, to affect materially the 
elasticity of the bone. 

Diagnosis. — The diagnosis will depend somewhat upon the history 
of the accident as well as upon the present symptoms. In no instance, 
where I could ascertain the cause, have I known an incomplete frac- 
ture of this variety produced by any other than an indirect blow ; and 
where the clavicle has been the seat of the fracture, the counter-blow 
has been received upon the end of the shoulder. The fact possesses, 
therefore, equal significance in its relation to either of the varieties of 
partial fracture ; but in the case of a partial fracture with a permanent 
curvature, the diagnosis would be complete without the history, while 
in this case it might not be, and a knowledge of the manner in which 
the accident occurred would, therefore, be of great importance. 

The signs, then, after a knowledge of the fact that a blow has been 
received upon the shoulder, are a node-like swelling upon the anterior 
or upper face of the clavicle, generally in its middle third, this swell- 
ing being hard, smooth, oblong ; the skin only slightly or not at all 
swollen or tender, and in no way discolored, as it would have been 
had the swelling upon the bone been the result of a direct blow, and 
the line of the axis of the bone unchanged. I have never detected 
motion or crepitus at the point of injury, yet we have seen that Blandin 
was able to detect both in one instance ; nor has it ever occurred to 
me to see the swelling upon the bone until two or three days after the 
injury was received. We are not likely, therefore, to recognize this 
accident immediately after its occurrence. 

Treatment. — In the case of the clavicle, neither bandages, slings, 
compresses, nor lotions, can be of much service. Yet no harm can 
arise from employing a simple sling and roller to confine the arm; 
and it is always proper to enjoin some degree of care in using the arm 
of the injured side. The consolidation will be speedily accomplished, 
and after a time the ensheathing callus will wholly disappear. 

If a similar accident should occur in any other of the long bones, 

as retentive and precautionary means, splints ought to be applied, at 

least for a few davs. 
j 

2. Partial Fracture without immediate and spontaneous restoration of 
the bone to its natural form. — The causes of this accident are the same 
with those which produce simple bending, or partial fracture with im- 
mediate and spontaneous restoration, from which latter they differ prob- 
ably in the greater extent of the bony lesion. Perhaps, also, they differ 



82 BENDING, PARTIAL FRACTURES, AND FISSURES. 



sometimes in the peculiar form and degree of the denticulation at the 
seat of the fracture ; in consequence of which an antagonism of the fibres 



Fig. 24. 



Fig. 25. 




Partial fracture with- 
out restoration of the 
hone to its natural form. 



Partial fracture of the clavicle without spontaneous restoration. From 
nature ; taken three weeks after the accident. 

takes place, preventing a restoration of the bone to 
its original form. 

They constitute a large majority of those ex- 
amples of partial fracture which come under our 
observation in the various long bones. In one 
hundred and forty-two fractures of the clavicle, it 
has been observed by me twenty times. In two 
hundred and nine fractures of the radius and ulna, 
it has occurred twelve times. Similar examples are 
met with, but much more rarely in the humerus, ribs, femur, tibia, and 
fibula. 

Very few surgeons have spoken of partial fractures in the clavicle, 
while Jurine, Syme, Liston, Miller, Norris, and many others, have 
declared that it is much more frequent in the bones of the forearm 
than elsewhere. This does not agree with my experience, according to 
which it occurs oftener in the clavicle than in the forearm ; a discrep- 
ancy which I cannot very well explain, except by supposing that, in 
the case of the clavicle, the accident has either been overlooked en- 
tirely or misapprehended. Blandin, who, we have seen, has reported 
five cases of partial fracture of the clavicle with immediate restoration, 
states distinctly that in two of these cases distinguished surgeons of 
Hopital Beaujon and Hotel Dieu failed to recognize it. 

Says Turner : " The next I shall descend to is that of the clavicle 
or- collar-bone, which I have found the most frequently overlooked, I 
think, of any other, till it has been sometimes too late to remedy, es- 
pecially among the children of poor people ; for, though they find these 
little ones to wince, scream, or cry, upon the taking off or putting on 
their clothes, yet, seeing that they suffer the handling of their wrists 
and arms, though it be with pain, they suspect only some sprain or 
wrench, that will go away of itself, without regarding anything further 



PARTIAL FRACTURE OF THE LONG BONES. 83 

or looking out for help ; whereas, this fracture discovers itself as easily 
as most others. For not only the eye, in examining or taking a view 
of the part, may plainly perceive a bunching out or protuberance of 
the bones when the neck is bared for that purpose, with a sinking 
down in the middle or on one side thereof, which will be still more 
obvious on comparing it with its fellow on the other side ; but when 
it is more obscure, and the bone, as it were, cracked only — a semi- 
fracture, as we say — yet, by pressing hard upon the part, from one 
extremity to the other, you will find your patient crying out when 
you come upon the place ; and by your fingers, so examining, some- 
times perceive a sinking farther down, with a crackling of the bone 
itself/ 71 

Erichsen, who regards all of these cases as mere bendings of the 
bones, remarks that it " most commonly occurs in the long bones, es- 
pecially the clavicle, the radius, and the femur." 2 He says, moreover, 
" Fracture of the clavicle in infants not un frequently occurs, and is 
apt to be overlooked. The child cries and suffers pain whenever the 
arm is moved. On examination, an irregularity, with some protuber- 
ance, will be felt about the centre of the bone." 3 The reader will not 
fail to recognize in these symptoms the incomplete fracture of which 
we are now speaking, although Erichsen evidently believes them to be 
examples of complete fracture. 

In addition to this testimony as to the frequency of these fractures 
in the clavicle, I will only mention that Johnson, in his review of 
Markham's Observations on the Surgical Practice of Paris, says that 
" many surgeons have noticed the incomplete fracture of the clavicle, 
as of other bones, which takes place in the young." 4 

Pathology. — The following experiment will assist in the elucidation 
of this point of our subject : 

Experiment — I bent the leg of a chicken five weeks old. It cracked 
under my fingers, and remained bent. Having waited a few seconds, 
and finding that it was not restored to position, I pressed upon it and 
made it straight. The chicken walked off without any limp. 

On the fourth day, before dissection, the bone looked as if it was 
still bent; but on removing the soft parts, the line of the axis of the 
bone was found to be straight. The areolar tissue under the skin was 
infiltrated with lymph, which was most abundant near the fracture, and 
gradually diminished toward each extremity of the limb. This effusion 
was confined almost entirely to the front of the limb, or to that side 
which had been broken, and constituted the greater part of the enlarge- 
ment, which I had noticed before the dissection was commenced, and 
which then felt like bone. 

On the front of the bone, also, underneath the periosteum, there was 
a loose, honeycomb deposit of ensheathing callus, about one line in 
thickness, and extending upwards and downwards about half an inch. 

1 Art of Surgery, by Daniel Turner, London. 1742, vol. ii, p. 255. 

2 Science and Art of Surgery, Phila. ed., 1854, p. 180. 

3 Op cit, p. 205. 

4 Lond. Med.-Chir. Kev., vol. xxxiv, p. 474, 1841. 



84 BENDING, PARTIAL FRACTURES, AND FISSURES. 



Fig. 26. 



This callus surrounded the bone in three-fourths of its circumference ; 
but there was no callus on its posterior surface. It was also deficient 
exactly along the line of fracture, in front and on 
the sides, in consequence of which an oblique groove 
remained, indicating the seat of the fracture. 

In three other experiments, the particulars of 
which are detailed in the earlier editions of this 
book, similar results were obtained. 

So early as the year 1673, a dissection made by 
Glaser demonstrated incontestably the existence of 
partial fractures in the shaft, and in the direction 
of the diameter of long bones. 1 Camper, in 1765, 
again described a specimen which he had seen ; 2 and 
Bonn, in 1783, added a third positive observation. 3 
M. Gimele is, therefore, in error when he ascribes 
to Campaignac the credit of having first proven by 
dissection their existence, in a paper communicated 
to the Academy of Medicine at Paris, in 1826. 
Campaignac, however, seems to have been the first 
who described very particularly the condition of this 
fracture. He has recorded the history and dissection 
of two cases, one of which occurred in the fibula, and 
one in the tibia. The first of these cases was a girl 
twelve years old, who survived the accident just 
eight weeks. The fracture had occurred near the 
middle of the bone, and upon the interior and in- 
ternal side; in which direction, resting against the 
tibia, the bone was found inclined. " The bony 
fibres had been broken at different lengths, almost 
exactly like what takes place in the branch of a 
tree which has been partially broken ; and, as we see sometimes in 
this latter case, the bundles of splintered bony fibres abutted upon 
themselves, and did not take their places when we endeavored to re- 
store them ; so the abnormal angle which the fibula represented could 
not be effaced, the ends of the divided fasciculi not restoring themselves 
to their respective places. This disposition might be especially seen 
toward the anterior part of the internal face, where a packet of fibres, 
coming from below, was braced against the upper lip of the division, 
which it thus held open. This opening at first made me think that 
the fragments could not have been well consolidated; but I assured 
myself that it was, and the fact was subsequently confirmed by the 
Academy of Medicine ; all the points which were in contact were 
found intimately united." 4 

Diagnosis. — The diagnosis is not difficult. The distortion indicates 
sufficiently the existence of a fracture, while the complete absence of 



Partial fracture ; after 
union is consummated. 



1 Malgaigne, op. cit., p. 44, from Th. Boneti Sepulchretum, 1700, torn, iii, p. 424. 

2 Essays and Obs. Phys. and Lit. of Soc. of Edinburgh, 1771, vol. iii, p. 537. 

3 Malgaigne, op cit., p. 44, from Descript. Thes 0>sium Morb. Hoviani, 1783. 

4 Des Fractures Incompletes et do.s Fractures Longitudinales des Os des Membres ; 
par J. A. J. Campaignac. Paris, 1829, pp. 9-10. 



PARTIAL FRACTURE OF THE LOXG BOXES. 85 

crepitus in nearly all cases, and of either overlapping or lateral dis- 
placement, must generally, especially where the accident has occurred 
in a child, sufficiently indicate that the fracture is incomplete. It will 
assist the diagnosis, also, to notice that these accidents are almost con- 
fined to the middle third of the long bones ; and they are produced 
usually by a bending of the bones, the forces operating upon the ex- 
tremities, and not directly upon the point which is broken. 

In complete fractures, also, preternatural mobility is so constant a 
sign as to be regarded as diagnostic, while here there is almost always 
a great degree of immobility at the seat of fracture. The angle made 
by the projecting extremities is usually rather gentle and smooth ; at 
other times it is abrupt, indicating a greater amount of fracture, or 
that the outer fibres are broken more irregularly. The power of using 
the limb is generally sensibly impaired, but not completely lost. 

Treatment. — Jurine, Murat, Campaignac, Gulliver, Malgaigne, w T ith 
some others, have noticed the fact that it is often difficult, and some- 
times quite impossible, to restore these bones to position ; a circum- 
stance which they have justly ascribed to that condition of the frag- 
ments described by Campaignac. The broken extremities of the fasciculi 
become braced against each other, and effectually resist all efforts 
to straighten the bone ; unless, indeed, so much force is used as to 
render the fracture complete : a result which, if it should chance to 
happen, need not occasion any alarm, since, while it enables us at once 
to restore the bone to line, it does not much increase the danger of 
lateral displacement and overlapping. That the fracture has become 
complete w T e may know by a sudden sensation of cracking, by the in- 
creased mobility, and by the crepitus, which is now easily developed. 

But we need not, on the other hand, be over anxious to straighten 
the bone completely, since experience has shown that after the lapse of 
a few weeks or months the natural form is usually restored sponta- 
neously. I am not now speaking of those cases in which the restoration 
occurs immediately, where it is probable that the splintered fibres offer 
no resistance to the restoration ; but only of those in which the bone 
straightens so gradually as to induce a belief that the broken ends are 
the cause of the resistance. To this variety of accident belong cases 
one, five, six, seven, and eight, published in my Report on Deformities 
after Fractures ; l in one of which the natural axis was resumed in less 
than four weeks. In a case mentioned by Gulliver, it required about 
the same time to render the bones of the forearm perfectly straight; 
and in one case mentioned by Jurine, at the end of six months it was 
" difficult to say which arm had been broken, and at the end of one 
year it was impossible." 

Jurine attributes this restoration to " muscular action, or more espe- 
cially to the reaction of the compressed bony plates ;" but while it is 
easy to understand how the reaction of the compressed fibres may ac- 
complish the gradual restoration, I am unable to understand in what 
manner muscular action contributes to this result, since most of the 
muscles attached to the long bones operate so much more energetically 

1 Trans. Am. Med. Assoc, vol. viii, 1855, pp. 392-5. 



'86 BENDING, PARTIAL FRACTURES, AND FISSURES. 

in the direction of their axes than in the direction of their diameters. 
Indeed, we have often seen these bones bent after complete fractures, 
and before the union was consummated, by muscular action alone. 

I repeat, then, that the gradual restoration of these bones is due to 
the same circumstance which produces at other times an immediate 
restoration, namely, the elasticity of the unbroken fibres, but which 
elasticity, in this latter instance, is, for a time, effectually resisted by 
the bracing of the broken fibres. At length, however, in consequence 
of the gradual absorption of the broken ends, the resistance is removed, 
and the bone becomes straight. If this absorption refuses to take 
place, and the fibres continue pressed forcibly against each other, as in 
the case described by Campaignac, then the bone remains permanently 
bent. 

Having straightened the bone as far as is practicable, it only remains 
to secure the fragments in place by suitable bandages or splints. If 
the restoration is incomplete, these means may assist the efforts of 
nature in accomplishing a gradual restoration. 

It is scarcely necessary to say that extension and counter-extension 
avail nothing in partial fractures. 

I 3. Fissures. 

These constitute the second principal form of incomplete fractures, 
or those in which the fracture is accompanied with no appreciable 
bending, which occur almost exclusively in inflexible bones, such as 
the compact bones of adults, and more often in the direction of their 
axes than of their diameters. They are complete so far as they extend, 
but they do not completely sever the bone so as to form two distinct 
fragments. They have been most frequently observed in the flat bones, 
such as the bones of the skull, and in the upper bones of the face ; oc- 
casionally in the long bones, both in their diaphyses and epiphyses, 
and rarely in the short bones. 

M. Gariel has reported, in the Bulletins de la Societe Anat, for 1835, 
a case of fissure of the inferior maxilla, occurring in a lad sixteen or 
eighteen years old. Palletta found a fissure extending partly through 
the third dorsal vertebra, in a man who had fallen upon his back 
eleven days before ; and M. Lisfranc has mentioned a remarkable case 
of fissure and partial fracture, with bending of five ribs in the same 
person. 1 Malgaigne believes that he has seen one example of this 
variety of incomplete fracture of the scapula, occurring through a por- 
tion of the infraspinous region. I have myself elsewhere recorded 
another, as having been found in the skeleton of Nimham, an Oneida 
Indian, who was a great fighter, and who died when about forty-five 
years old, in consequence of severe injuries received in a street brawl; 
but his death did not occur until four or five months after the receipt 
of the injuries. 

In addition to this fracture of the right scapula, five of his ribs were 
broken, and both legs, all of which, except the scapula, had united 
completely by intermediate and ensheathing callus. 

1 Des Fract. Incomplete et des Fissures, par J. A. J. Campaignac, 1829, p. 20. 



FISSURES. 87 

The scapula was broken nearly transversely, the fracture commencing 
upon the posterior margin at a point about three-quarters of an inch 
below the spine, and extending across the body of the bone one inch 
and three-quarters, in a direction inclining a little upwards, being 
irregularly denticulate and without comminution. The fragments were 
in exact apposition, and, throughout most of their extent, in immediate 
contact. They were, however, not consolidated at any point, but upon 
either side of the fissure there was a ridge of ensheathing callus, of from 
one to three or four lines in breadth, and of half aline or less in thick- 
ness along the broken margin, from which point it subsided gradually 
to the level of the sound bone. The same was observed upon the inner 
as well as upon the outer surface of the scapula. This callus had as- 
sumed the character of complete bone, but it was more light and spongy 
than the natural tissue, and the outer surface had not yet become 
lamellated. Its blood-canals and bone-cells opened everywhere upon 
the surface. 

Directly over the fracture, and between its opposing edges, no callus 
existed, but as the bone had lain some time in the earth before it was 
exhumed, it is probable that a less completely organized intermediate 
callus had occupied this space, and that, owing to the less proportion 
of earthy matter which it contained, it had become decomposed and 
had been removed. 

M. Yoillernier found the head of the humerus penetrated by two or 
three fissures; 1 and M. Campaignac has reported the case of a lad ten 
or twelve years old, who was compelled to submit to amputation of his 
arm at the shoulder-joint, in consequence of a severe injury, in which 
the humerus was found fissured from the insertion of the deltoid to near 
the condyles, extending through the entire thickness of the bone, and 
the edges of the fissure so much separated toward its lower extremity as 
to admit the blade of a knife. 2 Chaussier has related a case in which 
a criminal, who died soon after having submitted to the torture, was 
found to have a nearly longitudinal fissure of the radius in its upper 
fourth, and which penetrated half-way through the thickness of the 
bone. 3 Gulliver saw a fissure in the pelvis of an infant. 4 Malgaigne 
has seen two specimens of this fracture in the iliac bones, both of which 
belonged, as he thinks, to adults; in one, the fissure was limited to the 
internal table ; 5 and in the case of the lad reported by Gariel, as having 
a fissure of the inferior maxilla, there was also found a fissure of the 
left ilium, but which was' limited to the outer table. 6 

M. J. Cloquet has mentioned a case of fissure of the shaft of the 
femur passing through the condyles and extending upwards to near the 
middle of the bone. The fissure was produced by a bullet, which had 
completely traversed the bone from behind forwards, a little above the 
condyles. 7 M. Malgaigne has also represented, in one of his plates, a 

1 Malgaigne, op. cit., p. 35. 

2 Campaignac, Des Fract. Incomplet., etc., p. 24. 

3 Med. Legale, p. 447 et seq. 4 Gazette Med., 1835, p. 472. 

5 Op. cit., p. 34. 6 Bulletins de la Soc. Anat, 1835, p 24. 

7 These du Concours de Pathol. Externe, 1831, pi. xii, tig. 7. Also, Des Frac, 
etc., par Campaignac, 1829, p. 19. 



88 BENDING, PARTIAL' 

fissure of the femur extending along the front of the bone, somewhat 
irregularly, from a point a little below the trochanter minor to near 
the condyles. 1 The bone was presented to the Museum of Val-de- 
Grace, by M. Fleury ; but it is to be regretted that we have no farther 
account of this remarkable specimen. Certainly, in the complete 
absence of any farther history of the case, one might be justified in 
expressing a doubt whether it was not a fissure occasioned by the con- 
traction consequent upon exposure and drying after death. 

The following account of a fissure of the neck of the femur, of the 
same character with those which now occupy our attention, is copied 
from the proceedings of the "Boston Society for Medical Improve- 
ment," at its regular meeting in September, 1856 : 

" Partial Fracture of the Neck of the Femur in a man mt 44 years. 
Specimen shown by Dr. Jackson. The fracture, which appears as a 
mere crack in the bone, commences anteriorly just above, but very 
near to, the insertion of the capsular ligament, runs along this insertion 
for about an inch, and then extends directly upward to the margin of 
the head of the bone. From this last point it crosses the upper surface 
of the neck almost in a straight line, and at a little distance from the 
margin of the head, but afterward approaches very closely to this 
margin posteriorly ; it then turns downward and obliquely forward, 
and stops at a point about half way between the small trochanter and 
the head of the femur, and two-thirds of an inch or more anteriorly to 
the line of this trochanter. The fracture then involves about three- 
fourths of the neck of the bone ; the inner-anterior portion only being 
spared. There is considerable motion between the neck and the shaft, 
and the fracture could undoubtedly be completed without the appli- 
cation of any extraordinary force. Dr. J. referred to other cases of 
partial fracture; but a fracture of this sort, as occurring in this situa- 
tion, and in a fully adult subject, he believed had never before been 
described. There was, also, in this case, a transverse fracture of the 
same femur midway, with a split extending upward nearly to the neck 
of the bone ; and still further, a fracture of the spine. The patient, a 
laboring man, fell through two stories of a building and down upon a 
hard floor. On the same day he entered the Massachusetts General 
Hospital, and on the eighteenth day from the time of the accident he 
died. The femur is perfectly healthy in structure, and no changes are 
observable in the bone about the fracture." 2 

Whatever doubts may have been thrown upon the possibility of this 
accident, as applied to the neck of the femur, by the ingenious argu- 
ments of Robert Smith, of Dublin, 3 the question is now at least deter- 
mined by an incontestable fact. Dr. Smith had rendered it quite prob- 
able that both Colles and Adams were mistaken, and that the cases 
described by them were examples of impacted fracture, and not of 
partial fracture ; but, in arguing the improbability of its occurrence, 



i Op. cit.,p. 37, pi. 1, fig. 1. 

2 Bust. Med. and Surg. Journ., vol. lv, p. 351. See, also, Amer. Journ. Med. 
Sci. for 1857, p. 306, with engraving; and Bigelow on Hip Joint, p. 137. 

3 Treatise on Fractures in the Vicinity of Joints, etc., by Kobert ¥m. Smith, 
Dublin, 1854, p. 44 et seq. 



FISSURES. 89 

from the infrequency of fractures of the neck of the femur in early 
life, he overlooked the fact that there were two forms of incomplete 
fractures, and that it was only the " green stick" fracture which be- 
longed mostly to childhood, "fissures" being found most often in the 
bones of adults. Indeed, I think the example recorded by Tournel in 
the Archives de Medecine had already, so early as the year 1837, estab- 
lished the possibility of a "fissure" in the neck of the femur; although 
by Malgaigne this case has been mentioned as an example of that other 
variety of partial fractures which is almost peculiar to childhood, and 
in which the bones yield quite as much by bending as by breaking. 
But the man was eighty-five years old, and, having died three months 
and a half after the accident, a long crevice was found, extending 
nearly through the neck of the femur, partly within and partly without 
the capsule. 

I have seen, in Dr. Mutter's valuable collection of bones at Phila- 
delphia, a specimen of fissure of the trochanter major, which, it is be- 
lieved, occasioned the death of the patient by haemorrhage. 

Gulliver says there is an example of a fissure in a patella belonging 
to the museum of the Edinburgh College of Surgeons, the fissure 
traversing its articular face only. 1 

The first example of a fissure of the tibia is recorded by Corn. Stal- 
part Vander-Wiel, in 1687; and indeed this is, according to Campai- 
gnac, the first exact observation of this species of fracture which our 
science possesses, although its existence had been recognized by the 
most ancient authors. A servant had been kicked by a horse, and 
after a time, pain continuing in the limb, his surgeon, Dufoix, suspected 
a fissure of the tibia, and having cut down to the bone, a cure was soon 
effected. 2 

In the Dupuytren Museum, at Paris, there are two tibiae with linear 
fractures, one without history, and the other presented by MM. Mar- 
jolin and Rullier, " and which had been broken by a ball." 3 In the 
example related by Campaignac, a woman, having leaped from a 
second-story window, died immediately, and upon examination she was 
found to have three fissures in the upper portion of the left tibia, one 
only of which entered the articulation. 4 

Many examples of fissure from " perforating " gunshot wounds of 
the bone have been observed during the late war in this country ; but 
as these examples belong peculiarly to military surgery, they will be 
discussed more at length in the chapter on gunshot fractures. 

Duverney saw a priest who had fallen and bruised the middle of his 
left leg, the swelling and pain consequent upon which were subdued 
after a few days. The patient believed himself cured, and acted ac- 
cordingly. Suddenly, in the night, he was seized with an acute pain 
in the limb ; and on cutting down to the bone, a bloody serum escaped 
from between it and the periosteum, and the bone was discovered to be 
fissured longitudinally. Subsequently the tibia was trephined, but the 

1 Malgaigne, op. cit., p. 35. 2 Campaignac, op. cit., p. 17. 

3 Malgaigne, op. cit., p. 36. * Campaignac. op. cit., p. 21. 



90 BENDING, PARTIAL FRACTURES, AND FISSURES. 

fissure did not reach the marrow. He recovered completely in less 
than two months. 

The same writer mentions another case, in which a soldier received 
the kick of a horse in the middle of his left leg, which was followed 
immediately by great pain, and subsequently by much inflammation, 
and even gangrene of the skin. The wound, however, cicatrized 
kindly, but after three months he was seized suddenly with a severe 
pain in the limb, and, after the trial of many remedies, resort was 
finally had to the knife, when the tibia was seen to be discolored and 
cracked longitudinally. On the following day the bone was opened 
over the course of the fissure with a chisel and mallet, and the patient 
was at once relieved by the escape of a yellowish and very offensive 
matter. At the next dressing the bone was opened more freely by 
several applications of the trephine, and an abscess was exposed in 
the centre of the bone. The patient finally recovered after about four 
months. 1 M. Campaignac saw, also, at the hospital La Charite, the 
tibia of a woman, set. 38 years, upon which were found four fissures, 
the report of which case is accompanied with a woodcut illustration. 2 

Fissures may occur probably at all periods of life, but they are more 
frequently found in the bones of adults. Campaignac, however, men- 
tions a fissure of the humerus in a child ten or twelve years old, and 
Gulliver has seen a fissure in the pelvis of an infant. 

Etiology. — They may be occasioned by most of those causes which 
produce fractures in general, such as direct or indirect shocks; but 
they are occasioned much more often by direct blows, especially when 
inflicted upon bones imperfectly covered by soft parts, such as the tibia. 
Bullets, having violently struck or penetrated the bone, have frequently 
occasioned fissures. 

Their course may be parallel with the axis of the bone, oblique, or 
transverse; they are often multiple; some merely enter the outer lam- 
inae, others open into the cellular tissue, and others still divide both 
surfaces of the bone through and through ; and, according as they pene- 
trate more or less deeply the bone, their lips will be found to be more 
or less separated. They frequently extend into the joint surfaces. 

Diagnosis. — The signs which indicate the existence of a fissure must, 
in a large majority of cases, be insufficient to determine fully the diag- 
nosis during the life of the patient. It is not probable that such fissures 
could ever be clearly made out by the touch alone, where the skin is 
not broken, since the pain, swelling, suppuration, etc., are only charac- 
teristic of inflammation of the bone or of its coverings, and might be 
equally present whether a fracture existed or not. In those rare cases 
only in which the flesh is torn off, and the surface of the bone is brought 
directly under the observation of the eye, will the diagnosis become 
certain. 

Treatment. — Fortunately, an error in judgment in this matter will 
not materially, if at all, prejudice the interests of the patient; since, 
whatever may be the fact in other respects, if the bone, or its perios- 
teum, or its medullary tissue, is inflamed, and rest, with antiphlogis- 

1 Malgaigne, op. cit., p. 39 et seq. 2 Campaignac, op. cit., pp. 21-22. 



OSSA NASI. 91 

tics, does not accomplish its speedy resolution, incisions and perfora- 
tions become inevitable, if we would give either safety or relief to the 
sufferer. Accordingly, in the inflammation and suppuration consequent 
upon these fractures, we have seen that it has been occasionally found 
necessary to lay open the soft tissues freely, and even to trephine the 
bone at one or more points. 

Fissures in Cartilage. — I have once met w T ith a fissure in the thyroid 
cartilage, which constitutes, so far as I know, the only example upon 
record of a fissure in cartilage. 1 



CHAPTER VIII. 

FRACTURES OF THE NOSE. 

\ 1. Ossa Nasi. 

Of twenty-five cases of fracture of the ossa nasi recorded by me, 
only fourteen were seen by a surgeon in time to afford relief. It 
seemed to me necessary, therefore, that the student should be instructed 
how frequently the nature of this accident is overlooked by the friends, 
and even by the surgeon himself, to the end that he might be thus 
admonished of the necessity of always instituting, in such cases, careful 
and thorough examinations. In some of the cases recorded in my notes, 
where surgeons were called in time, and a deformity remains, it is not 
improbable that the accident was not recognized. The rapidity with 
which swelling ensues after severe blows upon the nose, concealing at 
once the bones, and lifting the skin even above its natural level, ex- 
plains these mistakes. The nose, also, is remarkably sensitive, and 
the patient is often exceedingly reluctant to submit to a thorough ex- 
amination. It ought, however, not to be forgotten that the omission 
on the part of the surgeon to do his duty will not always be excused, 
even though the patient himself has protested against his interference, 
especially where an organ so prominent, and so important to the har- 
mony of the face, is the subject of his neglect or mal-adjustment ; since 
the most trivial deviation from its original form or position, even to 
the extent of one or two lines, becomes a serious deformity. 

When the ossa nasi are struck with considerable force, from before 
and from above, a transverse fracture occurs usually within from three 
to six lines of their lower and free margins, and the fragments are sim- 
ply displaced backwards; or if the blow r is received partially upon one 
side, they are displaced more or less laterally. This is what will hap- 
pen in a great majority of cases, as I have proven by examinations of 
the noses of those persons who have been the subjects of this accident, 
and by repeated experiments upon the recent subject. 

1 Buffalo Med. Journ., vol. xiii, article entitled Fracture of the Thyroid Carti- 
lage. 



92 FRACTURES OF THE NOSE. 

These fragments are generally loose, and easily pressed back into 
place by the use of a proper instrument. A silver female catheter, 
which we have seen recommended by surgeons, may answer well enough 
in a few instances, but it will more often fail. The diameter of the 
meatus at the point where the instrument must touch in order to make 
effective pressure upon the ossa nasi, is on the average not more than 
two lines; and when the membrane which lines it is injured, it becomes 
quickly swollen, and reduces the breadth of the channel to a line or 
less. Under these circumstances, any instrument of the size of a female 
catheter could only be made to reach and press against the nasal process 
of the superior maxilla, which is too firm and unyielding to allow it to 
pass without the employment of unwarrantable force. In this way it 
happens that the operator is occasionally surprised to find how much 
resistance is opposed to his efforts to lift the bones, and, after repeated 
unsuccessful attempts, the case is not unfrequently given over. If, 
however, he had used a smaller instrument, he would have found almost 
no resistance whatever. A straight steel director, or sound, or some- 
times even a much smaller instrument, if possessing sufficient firmness, 
is more suitable than the catheter. For the same reason, also, one ought 
never to wrap the end of the instrument with a piece of cotton cloth, 
as some have, I suspect, without much consideration, recommended. 

What I have said of the facility with which these bones may be re- 
placed, when a proper instrument is employed, is true only when the 
treatment is adopted immediately, or at most within a few days after 
the accident. 

Boyer, Malgaigne, and others have noticed the fact that these frac- 
tures are repaired with great rapidity. Hippocrates thought the union 
was generally complete in six days ; and in a case which has come 
under my own observation, the fragments were quite firmly united on 
the seventh day. 

Nor has Malgaigne, whose observations are always very accurate, 
overlooked the fact, also, that their repair is effected without the inter- 
position of provisional callus, but, as it were, "par premiere intention." 
My own observation confirms this statement. Among all the specimens 
which I have seen in the various college and private collections illus- 
trating fractures of the ossa nasi, and amounting in all to over forty, 
in no instance has there been detected, after a careful examination, the 
slightest trace of provisional callus. 

I am not certain that it will always be found so easy to retain these 
loose fragments in place, as it is to replace them. The very swelling 
which takes place so promptly under the skin tends to depress the frag- 
ments, unsupported as they are by any counter-force; a tendency which, 
possibly, is in some instances increased by attempts on the part of the 
patient to clear his nostrils by snuffing and hawking. I have, in one 
instance, noticed very plainly a motion in the fragments when such 
efforts were made. How we are to remedy this, I am not prepared to 
say. None of the plans which I have seen suggested possess, in my 
estimation, very much practical value. Few patients will consent to 
the introduction of pledgets of lint, or of stuffed bags, or, indeed, of 
anything else, sufficiently far up into the nostrils to answer any useful 



OSSA NASI. 93 

purpose. The membrane is too sensitive and too intolerant of irritants 
to enable us to have recourse generally to such methods. Then, too, it 
would require, on the part of the surgeon, more than ordinary tact to 
accomplish so nice and delicate an adjustment of the supports from 
below as these cases demand, where the slightest excess of pressure, or 
the least fault in the position of the compress, must defeat the purpose 
of the operator. 

Yet, if one were disposed to make the attempt in certain cases where 
the comminution was very great, or where, for any other reason, the 
fragments would not remain in place, I think there could be no better 
plan than to push up in succession a number of small pledgets of patent 
lint, smeared with simple cerate, to each one of which there has been 
attached a separate string, so arranged as that their relative position 
may be recognized, and that they may at a suitable time be removed in 
the order of their introduction. 

The employment of canulas, as recommended by Boyer, B. Bell, and 
others, allows of the nostrils being stuffed without interfering materi- 
ally with the breathing; a provision, however, which is quite unneces- 
sary with a majority of persons, so long as there exists no impediment 
to the free admission of air through the fauces. 

With nicely adjusted compresses made of soft cotton or lint, and 
secured upon the outside of the nose with delicate strips of adhesive 
plaster or rollers, we shall be better able to prevent the fragments from 
becoming displaced outwards than by moulds of wax, of lead, or of 
gutta percha, under which it is impossible to see from hour to hour 
what is transpiring. 

The complicated apparatus devised by Dubois and recommended by 
Malgaigne, to lift the bones and retain them in place, seems to me indeed 
very ingenious, but destitute of a single practical advantage. 

A more considerable force than that which I have first supposed will 
break, generally, the ossa nasi transversely and a little above their mid- 
dle, while, at the same time, the nasal processes of the superior maxil- 
lary bones may suffer slightly. 

With neither of these accidents is the cribriform plate of the ethmoid 
likely to be broken or disturbed. Indeed, in numerous experiments 
made upon the recent subject, and in which the force of the blow was 
directed backwards and upwards, breaking and comminuting the nasal 
bones above and below their middle, with also the nasal processes of 
the superior maxillary bones, and the septum nasi, the cribriform plate 
of the ethmoid was, without an- exception, uninjured. The exceeding 
tenuity and flexibility of the septum nasi at certain points prevents 
effectually the concussion from being communicated through it to the 
base of the brain. If, therefore, after these accidents, cerebral symp- 
toms are occasionally present, as I have myself twice seen, 1 they must 
be due rather to the concussive effects of the blow upon the very sum- 
mit of the nasal bones, where they rest immediately upon the nasal 
spine of the os frontis, or to some direct impression upon the skull itself. 

The amount of force requisite to break in the nasal bones, at their 

1 Beport on Deformities after Fractures, Cases 16 and 18. 



94 FRACTURES OF THE NOSE. 

upper third, is very great; no less, indeed, than is requisite to fracture 
the os frontis. If they do finally yield at this point, then no doubt the 
base of the skull must yield also. Nor do I think patients could often 
be expected to recover from an accident so severe. To this class of frac- 
tures belongs the specimen contained in my museum, in which not only 
both of the nasal bones are sent in — the nasal spine being broken at its 
base — but also the os frontis is depressed; the nasal processes of the 
upper maxillary bones are broken and greatly displaced, and the an- 
terior half of the cribriform plate of the ethmoid is" forced up into the 
base of the brain. If it is meant that in these cases the patient is in 
danger from injury done to the base of the skull through the fracture 
and depression of the ossa nasi, we can appreciate the value of the 
opinion ; but we do not understand how this danger can exist when the 
nasal spine of the os frontis is not broken, and the upper ends of the 
nasal bones are not displaced backwards. But, admitting that it were 
possible in this way to force up the base of the skull, it does not seem 
to me that we ought to attach any value to the advice occasionally 
given, to attempt to restore the broken ethmoid by seizing upon the 
septum and pulling downwards. A force sufficient to break the base 
of the skull never fails to comminute and detach almost completely the 
septum nasi. We are to proceed in such a case as we would in a case 
of broken skull. We must lay open the skin freely, and with appro- 
priate instruments seek to elevate and remove, if necessary, the frag- 
ments. Indeed, after such accidents, we shall generally see plainly 
enough that death is inevitable, and that our services will be of no value. 

Occasionally, I have observed, the bones are neither broken at their 
lower ends nor through their central diameters, but only at their lateral, 
serrated, or imbricated margins. This is rather a displacement, or dis- 
location, than a fracture. It is more likely to happen, I think, in 
childhood than in middle or old age, as in the following example : 

Thomas Kelley, aged four years, was kicked by a horse. Two hours 
afterwards, when he was first seen by a surgeon, the nose and face were 
much swollen, and-the fracture was overlooked. 

One year after the accident, I found both nasal bones depressed 
through nearly their whole length, and especially in the lower halves. 
The right nasal process was also much depressed, and the right nostril 
obstructed. The lachrymal canals upon this side were closed. 

Sometimes the lower ends of the nasal bones are bent backwards, or 
laterally, constituting a partial fracture. 

A lad, aged ten years, was hit by one of his mates accidentally with 
his elbow, upon the left side of his nose. I was immediately called, 
and found the lower end of the left os nasi displaced laterally and 
backwards, so that it rested under the lower end of the right os nasi. 
There did not appear to be any fracture beyond that which was in- 
evitable by the mere separation of its serrated margins from the bone 
adjoining. The angle formed by the bone at the point where the bend- 
ing had occurred was smooth and rounded, and not abrupt as in a com- 
plete fracture. 

With a steel instrument, introduced into the left nostril, I attempted 
to lift the bone to its place. The membrane was very sensitive, and 



OSSA NASI. 95 

the patient very restless under my repeated efforts. I pressed upwards 
with considerable force, and succeeded at length in bringing the bone 
nearly into position. 

If there is more complete displacement, the upper ends are not 
usually forced backwards, but rather a very little forwards, from their 
articulations with the os frontis, and the bones then swing, as it were, 
upon the lower ends of the nasal spine, as upon a pivot. In this condi- 
tion they are very firmly locked, and it requires considerable force, 
applied under their lower extremities, to restore them to place. 

Such seemed to be the position of the bones in the case of the lad 
Kelley, already mentioned, and also in a German, whose nose was 
flattened by a severe blow when he was eleven years old, whom I saw, 
thirteen years after the accident, in the Buffalo Hospital. In this last 
example the bones Avere very much displaced backwards. 

In children, also, the nasal bones may be spread and flattened, the 
lateral margins not being depressed or displaced, but only the mesial 
line or arch forced back, so as to press aside the processes of the supe- 
rior maxilla; which deformity may become permanent. 

A block of wood fell upon a child three weeks old, as she was lying 
in the cradle. The nature of the injury was not understood by the 
parents, and no surgeon was called. The ossa nasi are now, twelve 
years after the accident, much wider than is natural, and depressed ; 
the nasal processes of the superior maxilla appearing to have been 
spread asunder. 

Jacob Kibbs, a German, aged seven years, fell from a height of forty 
feet, striking on his face. His parenfs did not suspect the injury, and 
no surgeon was called. Twenty-four years after this, I found the nose 
almost flat. The nasal bones appeared unusually wide, and were 
sunken between the processes of the upper maxillary bones, which 
latter might be recognized by two parallel ridges on each side, slightly 
rising above the level of the ossa nasi. 

Benjamin Bell and others have spoken of tedious ulcers, polypi, 
necrosis, fistula lachrymalis, abscesses, impeded respiration, and impair- 
ment of the sense of smell and of speech, as circumstances apt to result 
from these injuries, and it is certain that such consequences have occa- 
sionally followed ; but they must generally be regarded as accidents 
due to the state of the general system, and as having no connection 
with the fracture, except as this injury served to awaken certain vicious 
tendencies. 

A gentleman twenty-five years old was struck accidentally upon the 
right side of his nose by a board, and the ossa nasi were displaced to 
the left. A surgeon made an attempt to reduce them, but did not suc- 
ceed, and they have remained displaced ever since. The nose for a 
time was much swollen. A few months after the accident, a purulent 
discharge commenced from the right nostril, and at length an abscess 

O O 7 a 

formed in the right cheek. Two years later, when he came first under 
my notice, the nose still continued to discharge pus, and occasionally 
it bled freely. There was also a perforation of the septum, of the size 
of a three-cent piece, which had not ceased to enlarge. 

No hereditary maladies exist in the family, except that, on his father's 



96 FRACTURES OF THE NOSE. 

side, it has been generally observed that wounds do not heal kindly. 
The same is the fact with him. When a child, he was also very sub- 
ject to epistaxis; at sixteen, a pulmonary difficulty began, and he had 
more or less cough, with haemoptysis, for two years. Since then his 
health has been good. He is a lawyer by profession, but of late he 
has lived in the country, upon a farm, and has accustomed himself to 
much outdoor exercise. 

As to the prognosis in these fractures, I can only say that either 
owing to the ignorance and carelessness of the patients themselves, who 
neglect to call a surgeon in time, or to the difficulty of diagnosis, or to 
the greater difficulty in maintaining an adjustment of the fragments, 
it has hitherto happened that, after a fracture of the ossa nasi, more or 
less deformity has usually remained. I have seen but few which 
could be said to be perfectly restored. 

I 2. Fractures and Displacements of the Septum Narium. 

Fractures or displacements of the septum narium must occur to some 
extent in all fractures of the ossa nasi accompanied with depression ; 
but they are also occasionally met with as the results of a blow upon 
the nose which has been insufficient to break the bones, and in which 
only the cartilaginous portion of the nose has been bent inwards upon 
the septum. 

Of these simple, uncomplicated accidents, I have seen eight; in 
four of which no surgeon was employed, or surgical treatment of any 
kind adopted, and it is quite probable that only in a small proportion 
of all the cases was the nature of the accident recognized. Such, at 
least, has been generally the statement of the patients themselves. 
The same causes will explain this which have been invoked to explain 
similar oversights in cases of broken ossa nasi. To which we may 
add, as an additional reason why it may be overlooked, the frequency 
of lateral distortions or deviations in the natural development of this 
septum. 

The cartilaginous portion of the septum is that which is most fre- 
quently displaced by violence, and then it is usually at the point of 
its articulation with the bony septum. Next, in point of frequency, 
the perpendicular nasal plate is broken, and especially where it ap- 
proaches the vomer. We omit in this enumeration, of course, those 
cases where the nasal bones themselves are broken down, in most or 
all of which, as we have already said, the perpendicular plate is more 
or less fractured and displaced. We cannot say how often the vomer 
is broken, since it is beyond our observation, except in autopsies. It 
is probable, however, that the force of the concussion rarely reaches it, 
the cartilage or the perpendicular plate giving way first and easily. 

Where the deviation is only lateral, the results are less serious, yet 
sufficiently so, in a few instances, to demand our attention. Lateral 
obliquity of the lower portion of the nose follows generally, but not 
uniformly, a lateral displacement of the cartilage, and when it does 
exist, it is not always proportioned to the amount of displacement 
existing in the septum, so that the septum is then made to project 



FRACTURES AND DISPLACEMENTS OF SEPTUM NARIUM. 97 

obliquely across the nasal passage, causing often a serious obstruction 
and permanent inconvenience. In one instance, also/ 1 have known it 
to occasion a chronic catarrh. 

A lad, set. 15, was struck violently on the nose, Avhich became im- 
mediately much swollen, but no surgeon was called. Eight years 
after I found the septum displaced laterally, and to the left side, pro- 
ducing also a slight lateral inclination of the end of the nose. He 
was unable to breathe freely through the left nostril, and from the 
same side a catarrhal discharge had continued from the time of the 
accident. 

The following example, in which the accident has been followed by 
a morbid condition of the cutaneous glands, is of more difficult expla- 
nation : 

A young man, set. 23, called upon me, supposing that he had a 
polypus nasi. I found that in consequence of a fall upon the ice, seven 
years before, the septum narium had been displaced to the right so as 
to almost completely close this nostril. In very cold weather, when 
the vessels of the membrane are contracted, the passage is more free. 
The left nostril is proportionably wide. 

During the last four or five years, the right side of his face has been 
subject to profuse perspiration. It is almost constant in summer, and 
only occasional in winter. The line of division between the perspir- 
ing and non-perspiring portions of the face passes perpendicularly from 
the top of the centre of the forehead, along the ridge of the nose, and 
down to the centre of the chin. The phenomenon is due, perhaps, to 
an increased vascularity in the right side of the face ; possibly to some 
peculiarity in the condition of the nervous trunks, occasioned by the 
nasal obstruction. 

A depression of the cartilage forming a portion of the ridge of the 
nose is necessarily accompanied with a corresponding degree of lateral 
displacement, with or without fracture, of its perpendicular portion, 
and produces, therefore, not only great deformity, sometimes a complete 
flattening of the end of the nose, but, also, in some instances, complete 
obstruction of the nostrils. 

We conclude, from all that we have seen, that fractures and dis- 
placements of the septum narium are generally followed by permanent 
deformity, and occasionally with still more serious results. We suggest, 
therefore, a more careful examination in recent injuries, with a view to 
the ascertainment of its lesions, and it would be well, certainly, if we 
could devise some reliable mode of treatment. 

It is doubtful whether a partition so thin and unsupported can ever 
be well adjusted and supported by artificial means. We possess, how- 
ever, some advantages in the treatment of this accident which we do 
not in the treatment of broken ossa nasi, viz., facility of observation 
and of approach, and if we can do little with plugs and supports in 
the one case, we may possibly do more in the other. Nothing seems 
more rational, then, than to plug carefully and equally each nostril 
with pledgets of lint, while we cover the outside of the nose completely 
with a nicely moulded gutta-percha splint or case, w T hich ought to be 
made to press snugly upon the sides, and permitting these to remain 



98 FRACTURES OF THE NOSE. 

for several weeks, or until the cure is completed. The papier maehe 
of Dzondi, employed by him in cases of broken ossa nasi, would be 
equally applicable here; but the gutta-percha, as being more plastic, 
and hardening more quickly, ought to be preferred. 

Attempts to remedy the deformities of the nose, at a later period, 
belong to the department of anaplastic surgery, and the modes of pro- 
cedure must be varied according to the circumstances of the case. 

The following example will serve as an illustration of what may 
sometimes be accomplished in these cases: 

A young man fell from a two-story window, striking upon his face. 
A surgeon was called, but he did not discover the nature of the injury 
to the nose. 

One year after the accident he called upon me for relief. The car- 
tilaginous portion of the septum was broken just at the ends of the 
nasal bones, and forced backwards about three lines, producing a strik- 
ing depression at this point of the ridge of the nose, while at the same 
time the end of the nose was thrown up. The deformity was very 
unseemly, and annoying both to himself and to his friends, who at first 
could scarcely recognize him. 

I introduced a narrow, sharp-pointed bistoury through the skin of 
the nose on the right side, and resting its edge upon the ridge at the 
junction of the cartilage with the ossa nasi, I cut the cartilaginous 
septum directly backwards about three lines, and then making a 
gradual curve with my knife, I cut downwards about eight lines to- 
ward the end of the nose. The intercepted portion of cartilage could 
now be easily lifted with a probe, and the line of the ridge of the nose 
completely restored. It was at once apparent, also, that lifting the 
cartilage would depress the tip of the nose and restore its symmetry. 

To retain the cartilage in place, I constructed a gutta-percha splint 
of the length and shape of the nose, but so formed along its middle as 
that it would not press upon the cartilage which I had lifted, resting 
well upon the ossa nasi, but not touching the ridge from the lower 
ends of these bones to the tip of the nose, at which latter point it again 
received support. I now passed a needle, armed with a stout ligature, 
through the upper end of the uplifted cartilage, transfixing, of course, 
the skin on both sides of the nose, and this I tied firmly over the splint. 
This accomplished the important object of pressing backwards and 
downwards the tip of the nose, and thus tilting up the upper part of 
the ridge and septum, and of more effectually securing the cartilage in 
place by lifting it directly with the ligature. On the second day the 
ligature was removed, but the splint was continued two weeks, during 
most of which time a band was kept drawn across the lower end of the 
splint, and tied behind the neck. 

To prevent the cartilage from falling back when final cicatrization 
occurred, I pressed the sides of the splint firmly toward each other, 
just below the incision, so as to force as much as possible the walls of 
the nares into the fissure of the septum, made by lifting it up. The 
result is a complete and perfect restoration of the nose to its original 
form. 

Dr. James Bolton, of Richmond, Ya., has devised a very ingenious 



FRACTURES OF THE MALAR BONE. 99 

mode of rectifying an old displacement of the septum nasi. He makes 
a stellate incision of the septum in such a manner as to form of it about 
eight triangles with their apices converging to a common centre. He 
then seizes each triangle separately with a pair of forceps, and breaks 
it at its base without detaching it. Having thus comminuted the sep- 
tum, he is able to restore it to position and retain it until consolidation 
is effected. 1 



CHAPTER IX. 

FRACTURES OF THE MALAE BONE. 

I have been unable to find any records of a simple fracture of the 
malar bone, that is to say, of a fracture unconnected with a fracture of 
other bones of the face. It is probable, however, that it sometimes 
-occurs, but that, not being accompanied with much displacement, it is 
overlooked. I have myself seen a fracture of the upper margin, or 
of that portion which constitutes a part of the orbital border, in two 
or three instances, while I was unable to detect any other fracture 
among the bones of the face ; but it is by no means certain that other 
fractures did not exist, perhaps in some of the bones which form the 
socket, or in the superior maxilla, as mere fissures, or as fractures with 
only slight displacement. The prominence of the malar bone, and 
especially the sharpness of its orbital margin, would enable the surgeon 
to detect easily the smallest displacement, or even a fissure, while a 
much more extensive displacement elsewhere would escape detection. 

The two upper maxillary bones form, as they are placed opposite 
to each other, an irregular arch, one end of which rests upon its fellow, 
at the intermaxillary suture, and the other end rests upon the nasal 
and frontal bones ; while over the centre of the arch is situated the 
malar bone. The force of a side blow upon the malar bone will ex- 
pend itself, therefore, chiefly upon the base of the maxillary apophysis, 
as being in the line of the direction of the force. The force continuing 
to act, after the apophysis is broken, the portion of the superior max- 
illa above the floor of the nares will fall inwards toward the septum, 
while the portion below will tilt outward, and open the intermaxillary 
suture along the roof of the mouth. This suture will also open more 
widely in front than behind, owing to the greater depth of the suture 
in front. 

These observations I have verified by several experiments made 
with a hammer upon a clean skull. 

One might suppose that it would be a very easy matter to restore 
these bones to place upon the naked skull, after such an accident. 
Certainly it would be very desirable to do so, were this accident to 
occur to any patient, since the malar bone is slightly depressed, the 

1 Bolton, Richmond Med. Journ., April, 1868, p. 241. 



100 FRACTURES OF THE MALAR BONE. 

nostril upon this side is nearly closed, and the line of the teeth is dis- 
turbed, and it is possible also that an opening might be established 
between the nose and mouth immediately back of the incisors. In 
fact, however, I found the restoration impossible. It could not be ac- 
complished by an instrument within the nose pressing outwards, nor 
by pressing inwards upon the teeth and alveoli ; not, certainly, without 
very great and unwarrantable force. The difficulty consisted simply 
in the antagonism of the serrated margins of the intermaxillary suture, 
which, projecting one or two lines on each side, could not be made to 
interlock again, but were firmly braced against each other. 

I shall not find it necessary to report in detail the results of the ex- 
periments, but shall content myself with stating that by the second 
blow, in the last experiment, the skull was also found broken at its 
base through the lesser wings of Ingrassias; the force of the blow 
having been conveyed, apparently, along the orbital plate of the supe- 
rior maxilla and os planum. 

This is the only example from four experiments in which the frac- 
ture extended through the dental arcade, and it was the result of the 
first blow. The fracture of the base of the skull by the second blow 
indicates the possibility of producing a fatal lesion of the brain or of 
its bloodvessels by a blow upon the malar bone. 

General Summary. — A fracture of the superior maxilla has occurred 
in every instance ; and twice when the malar bone was not broken : in 
each of the two last cases the antrum alone was broken, and the de- 
pression of the malar bone was scarcely noticeable. In the second of 
these cases, the fracture extended also through the dental arcade. 

In three cases the nasal apophysis has broken near the base, and in 
one case at two points. One of the three fractures of the nasal apophy- 
sis was accompanied with a diastasis of the superior maxilla through its 
intermaxillary suture. 

The malar bone has been broken twice by the first blow, and always 
when the blow has been repeated. The orbital margin and orbital 
plate have been fissured twice, the outer portion of the orbital plate 
being pushed a little into the socket. Once this plate has been pushed 
downwards. 

The zygoma has been broken three times, and always transversely, 
a little beyond its centre, or where the bone is the most slender and 
most convex. 

The ethmoid has been broken three times, and always longitudinally 
through the orbital plate. 

The sphenoid has been broken once, at the base of the skull. 

In addition to these observations upon the naked skull, I have seen 
at least four examples, which illustrate the relative infrequency of frac- 
tures of the malar bone, as compared with fractures of the superior 
maxilla and of the other bones of the face, even when the blow is re- 
ceived directly upon the malar bone. 

Pat. Maloney, set. 55, fell about twenty feet and struck upon his 
face. Six weeks after the accident, while an inmate of the Buffalo 
Hospital of the Sisters of Charity, I found the right malar bone de- 



FRACTURES OF THE MALAR BONE. 101 

pressed, but I could not trace any line of fracture in the malar bone. 
I think the antrum of the superior maxilla was broken, and the malar 
bone forced in upon it. 

Thomas Crotty, set. 20, was struck with a hoop, August 15, 1855. 
He was seen immediately by a surgeon in Canada, but the fracture 
was not recognized. Five days after, he called at my office. I found 
the outer portion of the right malar bone lifted slightly, and the lower 
and anterior angle depressed about three lines, as if this portion had 
been forced in upon the antrum. 

The third case will be found reported under fractures of the superior 
maxilla, and the fourth has been brought under my notice in the prac- 
tice of Dr. Wadsworth, of this city, the fracture having been occasioned 
by collision with the head of another man. 

Prognosis. — The malar bone may be depressed, as we have seen, to 
the extent of two or three lines, without being broken. This accident 
will be more properly considered under fractures of the upper maxilla. 
A fracture of the malar bone implies, therefore, generally, that great 
force has been applied, and that other fractures exist as complications. 
This may not be true, however, when only the orbital margin of the 
socket is broken. If the orbital plate is broken, and a portion of it is 
pushed into the socket, it may occasion a slight protrusion of the ball, 
as in two cases related by Dr. Neill as fractures of the upper maxilla, 
and as has been noticed in the experiments already referred to. This 
protrusion of the eyeball will probably continue, in some degree, as 
long as the bones remain displaced. It is quite probable, however, 
that in some cases, after severe injuries of the face, a moderate protru- 
sion of the eyeball is due entirely to extravasation of blood in the 
socket; a circumstance which would be likely to follow a fracture of 
the bones of the socket, and to increase temporarily the protrusion of 
the eye. 

If the body of the bone is broken entirely through, and coma super- 
venes upon the accident, there is some reason to fear that the skull is 
fractured at its base, and the prognosis ought to be grave. 

Treatment. — If there is only a fissure of the orbital margin, it will 
not require attention ; but if the fissure extends through the orbital 
plate, and at the same time the anterior and inferior margin of the 
bone is depressed, in consequence of which the orbital plate is tilted 
upwards and made to push forward the eyeball, the propriety of surgi- 
cal interference may be considered. If this protrusion is considerable, 
and evidently due to the displaced bone, an attempt should be made 
to lift the body of the malar bone, and thus to restore to position its 
orbital plate. The method of accomplishing this I shall describe par- 
ticularly when speaking of fractures of the superior maxilla with de- 
pression of the malar bones. 



102 FRACTURES OF THE UPPER MAXILLARY BONES. 

CHAPTER X. 

FRACTURES OF THE UPPER MAXILLARY BONES. 

These fractures assume so great a variety in respect to form, situa- 
tion, and complications, that it would be impossible to speak of them 
systematically, or to establish anything but very general rules as to 
treatment and prognosis. 

They may be broken, or loosened from each other or from the other 
bones with which they are articulated, with or without any farther 
fracture ; the nasal processes may be broken, and generally this accident 
is accompanied with a fracture of the nasal bones also ; the malar bones 
may be forced in, carrying with them a portion of the outer wall of the 
antrum ; the alveoli may be broken and more or less completely de- 
tached ; and either of these several fractures may be complicated with 
fractures of the other bones of the face, or of the base of the skull even. 

Treatment. — When the harmonies of the upper maxillary bones are 
only slightly disturbed, nothing but a retentive treatment is necessary. 

A man was thrown backward from a loaded cart, one wheel of the 
cart passing over his face. He was taken up unconscious, but when 
I saw him on the following morning, his consciousness had returned. 
The right malar bone was broken, and forced down upon the antrum 
about three lines. Both superior maxillae were loosened from their 
articulations, and could be moved laterally, the motion producing a 
slight grating sound. The same motion and grating occurred when- 
ever he attempted to swallow. No effort was made to elevate the 
malar bones, nor did I find any means necessary to retain the maxil- 
lary bones in place, the amount of displacement being very inconsid- 
erable, and never sufficient to be observed by the eye. Cool lotions 
were applied constantly to the face, and the patient was sustained by a 
liquid diet. On the ninth day all motion of the fragments had ceased, 
and on the twenty-seventh day the patient was completely recovered, 
with only the depression of the malar bone remaining. 

Sargent, of Boston, reports a similar case, in which a slight separa- 
tion of the maxillary bones united promptly and without any retentive 
apparatus. 1 

But in a case in which the superior maxillary bones had been more 
completely torn from their connections, complicated with other severe 
injuries, I found it necessary to support the fragments by closing the 
lower jaw upon the upper, and by suitable bandages. The patient 
died, however, on the twelfth day. 2 

Graefe recommends, where the bones are thus extensively separated 
and displaced, an apparatus made of steel, and suitably covered, which 

i Boston Med. and Surg. Journ., vol. lii, p. 378. 

2 Report on Deformities after Fracture. Trans. Amer. Med. Association, vol. 
viii, p. 375, Case IV. 



FRACTURES OF THE UPPER MAXILLARY BONES. 103 

is to be applied against the forehead and buckled under the occiput. 
From the two sides descend a couple of steel plates, which, having ar- 
rived at the free border of the upper lip, are reflected upon themselves, 
and are made to support upon their extremities long silver gutters, in- 
tended for the reception of not only the displaced teeth and alveoli, but 
also those teeth which are firm. 1 Vulcanized rubber might be substi- 
tuted for the silver in this apparatus. 

Wiseman having been summoned to a child with his whole upper 
jaw forced in by the kick of a horse, " beating the ethmoides quite in 
from the os cribriforme," and forcing the palate bone against the back 
of the pharynx, found great difficulty in securing a permanent read- 
justment. At first he attempted to introduce his finger back of the 
bone, but failing in this, he bent an instrument into the form of a 
hook, and passing it between the bone and the pharynx, he easily re- 
placed the fragments. But, on removing the instrument, they were 
again displaced. Immediately he had constructed an instrument by 
which the bones could be not only easily reduced, but also retained in 
place, extension being made by the hands of the child, his mother, and 
others, alternately. In this way the reunion was finally effected, and 
" the face restored to a good shape, better than could have been hoped 
for." 2 

Harris, of New York, mentions a case in which a child, two years 
old, having fallen from a height of fifty feet upon the pavement, was 
found to have a diastasis of both the superior maxillary and palate 
bones; the separation being sufficient to admit the little finger, and 
extending from between the alveoli which supported the central in- 
cisors, to the soft palate. It is not said whether any efforts were made 
to reduce the bones, but six weeks after the injury was received they 
were still open, and it was proposed to close the space by a plastic 
operation as soon as the condition of the patient would warrant such a 
procedure. 3 

I suspect that in this example, as in my experiments referred to 
under fracture of the malar bone, it was found impossible to adjust the 
bones and close the intermaxillary suture, and for the same reasons. 

If, in consequence of a blow received upon the ossa nasi, the nasal 
processes of the superior maxillae are broken down, they may be lifted 
and adjusted in the same manner as the ossa nasi. 

I have seen several examples of this accident, and I have in my 
cabinet a specimen, in which the nasal bones being driven in by the 
kick of a horse, the nasal process upon the left side is broken off just 
above the root of the cuspid tooth, and its upper end inclined inwards 
toward the nasal passage and backwards, until it is completely buried. 
In this situation it has become firmly united to the. bony and soft tissues 
into which it was brought in contact. 

The following example will illustrate some of the complications and 
difficulties connected with a depression of the malar bone, and conse- 
quent fracture of the antrum maxillare. 

1 Traite des Frac. etc., par L F Malgaigne, p. 373. 

2 Chirurgical Treatises, by Richard Wiseman, 1734, p. 443. 

3 New York Journ. Med., vol. xiii, 2d ser., p. 214. 



104 FRACTURES OF THE UPPER MAXILLARY BONES. 

M. P., of Colesville, aged about 34 years, was thrown from a height, 
striking upon his face, forcing the right malar bone down upon the 
antrum of the superior maxilla. Dr. L. Potter, of Varysburg, and 
myself were called. 

The deformity produced by the sinking of the malar bone was very 
striking, and both the patient and myself were very anxious to have it 
remedied, if possible. AYe found some of the teeth upon the side of 
the fracture loose, and we determined to extract them, and press up 
the bone with an instrument introduced through the empty sockets. 
The first attempt to extract a molar tooth, however, brought down 
several teeth, and the whole floor of the antrum. The detachment of 
this fragment was also now so complete that we believed it necessary 
to remove it entirely, a labor which was accomplished with infinite 
difficulty, and with no little hazard to the patient, as dissection had to 
be extended very far back into the throat, and in the end it was not 
effected without bringing out, attached to the fragment of maxillary 
bone, a considerable portion of the pyramidal process of the os palati. 

The time occupied in this operation was at least one hour, during 
which we were every moment in the most painful apprehensions lest 
we should reach and wound the internal carotid, which lay in such 
close juxtaposition to the knife that we could distinctly feel its pulsa- 
tion. After its removal, the haemorrhage was for an hour or more 
quite profuse, and could only be restrained by sponge compresses pressed 
firmly back into the mouth and antrum. 

When the haemorrhage was sufficiently controlled, we proceeded to 
examine the antrum, the floor of which being removed entire, per- 
mitted the finger to enter freely. The restoration of the malar bone 
was now accomplished without much difficulty, and with only mod- 
erate force. 

Two years after the accident the face presented, externally, no traces 
of the original injury. The malar bone seemed to be as prominent as 
upon the opposite side, and there was no perceptible falling in where 
the teeth and alveoli were removed. During several months after the 
removal of the bone, the antrum continued to discharge pus, but at 
length a semi-cartilaginous structure closed in the cavity below, en- 
tirely reconstructing its floor, and the discharge ceased. Since then he 
has experienced no further inconvenience. 

I wish to propose two or three expedients for lifting the malar bone 
when it has been thrust down, which may in certain cases be substi- 
tuted for the mode which has been heretofore generally adopted. 

In many instances no difficulty will be experienced in resorting to 
the usual method. The recent loss of one or more teeth opposite the 
floor of the broken antrum, or the complete displacement of a tooth 
by the accident itself, will give an opportunity for the perforation of 
the antrum through the open socket, and for the introduction of a 
suitable instrument for lifting the depressed bone. Unless, however, 
the opening is quite large, the instrument employed must be so small, 
such as a straight steel sound or a female catheter, as to expose the 
parts against which its end is made to press, to some risk of being 
broken and penetrated. It is even possible in this way to penetrate 



FRACTURES OF THE UPPER MAXILLARY BONES. 105 

the socket of the eye, and thus inflict serious injury upon the eye itself. 
Yet, with some care, such accidents may be avoided, and it is probable 
that in the cases supposed, where the sockets of the teeth opposite the 
base of the antrum are open, this method will continue to have the 
preference. 

But if the teeth remain firm in their places, or if they have been 
some time removed, and the sockets are filled up, and w r e wish to enter 
the antrum at its base, we must either drill through its anterior wall 
above the roots of the teeth, or we must proceed to extract a tooth. 
The first method gives an inconvenient opening, and one through 
w T hich it will be necessary to use a curved instrument ; but yet it is a 
method far less objectionable than the extraction of a tooth which is 
firm, or which is even tolerably firm, in its socket, and which may 
require the forceps for its removal. The objections to this latter pro- 
cedure were suggested by the tedious and painful operation already 
detailed. The first attempt to extract a tooth brought down the whole 
floor of the antrum, with all its corresponding teeth, and the pyramidal 
process of the palate bone. The tooth was already loose, and we 
thought it might easily be taken out, but it had not occurred to us 
that it was loosened by the comminuted condition of the walls of the 
antrum, and of the dental arcade. The experiments made upon the 
dead subject would seem to show that this fracture and comminution 
of the alveoli is not a very frequent result of a fracture of the antrum 
produced by a. blow upon the malar bone; yet it may happen, and 
whenever it does, the attempt to extract a tooth must always expose 
the patient to the same hazards. Certainly it is no trifling matter to 
pull away all of a man's upper teeth upon one side, and to open freely 
into a broad cavity which might never close again, and which, in this 
event, must always serve as a place of lodgment for particles of food, 
and for foul secretions, to say nothing of the external deformity which 
it is likely to produce, and of the severity and even danger of the 
operation. 

I wish, then, to suggest certain procedures, the value of which I have 
been able to determine by experiment upon the living subject in two 
or three cases, and which I have carefully and frequently tested upon 
the cadaver. 

First, we ought to attempt to lift the bone by putting the thumb 
under its zygomatic process and body within the mouth. If the bone 
is thrown directly dowmvards, or downwards and backwards, this 
method can scarcely fail ; and even when it is thrown downwards and 
forwards, so as to press into the antrum, it is likely to succeed. If r 
however, for any reason, the thumb cannot be brought to bear upon 
its under surface, we may make a small incision upon the cheek over 
the anterior margin of the masseter muscle, where its insertion into the 
malar bone terminates, and pushing a strong blunt hook under the 
bone, we may lift it with ease. 

Where the depression of the malar bone is in the direction of the 
anterior and superior angle, these means may not be found available, 
and we may then employ a screw elevator, an instrument which I find 
already constructed in a case of trephining instruments made for me 

8 



106 FRACTURES OF THE UPPER MAXILLARY BONES. 

by Mr. Luer, of Paris, and which I have often used, and constantly 
recommended to my pupils, in certain cases of fractures of the skull. 
The instrument ought to be made of the best steel, and with a broad, 
sharp-cutting thread. A slight incision being made through the skin, 
and down to the centre of the malar bone, the elevator is then screwed 
firmly into its structure, and now its elevation and adjustment may be 
accomplished with the greatest ease. 

Malgaigne remarks: "In all complicated fractures of the upper jaw, 
there is one principle which surgeons cannot too much studv, namely, 
that all fragments, however slightly adherent they may be, ought to be 
most carefully preserved, and they will be found to unite with wonder- 
ful ease. This remark had already been made by Saviard, Larrey 
insists strongly upon it, and we have seen that M. Baudens, so great 
an advocate for the removal of loose fragments, has declared for these 
fragments a special exemption." 1 

Malgaigne has here especial reference to fractures of the dental 
arcade, and to fractures implicating the alveoli, and extending more or 
less into the body of the bone. 

It would be an error, however, to suppose that a reunion will in 
these cases uniformly take place. Exceptions have occurred in my 
own practice, the fragments becoming#loosened and completely detached 
after the lapse of several weeks. In the case related by Miller, the 
whole floor of the antrum having been broken off, in an unskilful 
attempt to extract the second right upper molar, it was found impos- 
sible to make it unite, and it was subsequently removed. 2 Such un- 
fortunate results certainly may sometimes be reasonably anticipated. 
Yet they occur so seldom as to justify the opinions and practice advo- 
cated by Malgaigne. 

In some instances, where fragments are displaced, carrying with 
them several teeth, while others in the same row remain firm, it will 
be sufficient to close the mouth and apply a bandage as for fracture of 
the inferior maxilla; in others, the teeth and their alveoli ought to be 
fastened with silk, or gold or silver thread ; gold, silver, gutta-percha, 
or vulcanite clasps may be applied to the teeth and jaw. 

In a case of fracture of the right superior maxilla, reported by Baker, 
of Norwich, N. Y., complicated with a fracture of the inferior maxilla, 
the alveoli were retained in place very perfectly by a mould of gutta- 
percha. 3 Neill, of Philadelphia, has also reported three cases of frac- 
ture of the bones of the face, involving the superior maxilla, in two of 
which the eyes were made to protrude more or less from their sockets. 4 
The loosened alveoli were made fast by wire. The subsequent de- 
formity was inconsiderable, yet in no instance was the restoration com- 
plete. 5 The same method was adopted successfully by a surgeon in 
Virginia, in the case of a negro fifty years old, where most of the teeth 

1 Op. cit. , vol. i, p. 876. Paris ed. 

2 News Letter, April, 1854. Also, Bost. Med. and Surg. Journ., vol. li, p. 264. 

3 NVw York Journ. of Med., vol. i, 3d ser., p. 362. 

4 See " Observations," under Fractures of the Malar Bone; in which the orbital 
plate of the malar bone was pushed into the sockets. 

£ Phil. Med. Exam., vol. x, new ser., pp. 455-8. 



FRACTURES OF THE ZYGOMATIC ARCH. 107 

of the left upper jaw were forced into the mouth, carrying with them 
their corresponding alveolar processes. The teeth remained firm in 
their sockets, but the separation of the bone was complete, the fragment 
being held in place only by the mucous membrane of the mouth. On 
the eighth day the surgeon found that the negro had removed the wire, 
and also the cork from between his teeth, and the maxillary bandage; 
but the soft parts had already united, and the bones showed no ten- 
dency to displacement. His recovery was speedy, and it was accom- 
plished without any farther treatment. 1 

Our experience during the war of the rebellion in this country con- 
firms most of the observations heretofore made in relation to these 
fractures. Owing to the extreme vascularity of bones composing the 
upper jaw, the fragments have been found to unite, after the most 
severe gunshot injuries, with surprising rapidity ; the amount of necrosis 
and caries being usually inconsiderable, compared with the amount of 
comminution. The same anatomical circumstance, namely, the vas- 
cularity, has rendered these accidents peculiarly liable to troublesome 
haemorrhages, both primary and secondary. 

The Surgeon-General reports that of 4167 wounds of the face, tran- 
scribed from the reports from the beginning of the war to October, 
1864, there were 1579 fractures of the facial bones, and of these 891 
recovered, 107 died — the terminations are still to be ascertained in 581 
cases. He farther remarks that secondary haemorrhage has been the 
principal source of fatality in these cases, and that frequent recourse 
has been had to ligation of the carotid, with the result of postponing 
for a time the fatal event. 2 



CHAPTER XL 

FRACTURES OF THE ZYGOMATIC ARCH. 

The zygoma, strictly speaking, is formed in a great measure by the 
body of the malar bone, and it is broken whenever the malar bone is 
completely separated through any portion of its body ; but I propose to 
confine my remarks to that portion only which is composed of the 
two processes, called respectively the zygomatic processes of the malar 
and temporal bone. 

Duverney relates a case in which a young child, having in his mouth 
the end of a lace-spindle, fell forwards and thrust the spindle through 
the mouth from within outwards, breaking the zygoma in the same 
direction, and leaving the fragments salient outwards. 3 To which case 
of outward displacement Packard, in a note to Malgaigne's work on 
fractures, etc., has added a second. 4 

1 Amer. Med Gazette, vol. viii. new ser., p. 106. 

2 Circular No. 6, Washington, Nov. 1, 1865, p. 20. 

3 Bulletin de la Societe Anatomique, p. 138, 1810. 

4 Op. cit., p. 289, vol. i. 



108 FRACTURES OF THE ZYGOMATIC ARCH. 

I know of no other examples in which the fragments have been 
thrust outwards. A reference to my experiments upon the naked skull 
will, however, show that the zygoma may be broken and displaced in 
the same direction, by any force which shall fracture the superior 
maxilla, and depress the anterior margin of the malar bone. In my 
experiments this has happened three times, and always at the same 
point, viz., a little beyond the middle of the zygoma, near where the 
suture which joins the two processes terminates below. The fractures 
were always transverse, and not in the line of the suture. They were 
therefore fractures of that portion of the zygoma which belongs to the 
temporal bone. 

I suspect, also, that to this class of cases belongs the example re- 
lated by Dupuytren, in which the patient having died on the fifth day, 
from the effects of the cerebral concussion, the autopsy disclosed " a 
fracture through the zygomatic arch ; and that part of the superior 
maxillary bone which constitutes the antrum was driven in." 1 

In another case mentioned by Dupuytren, produced by a direct blow, 
the fracture was compound and comminuted, and although the frag- 
ments were raised easily by an elevator, suppuration ensued beneath, 
and the matter was discharged within the mouth. 2 

Tavignot reports a case of fracture of this arch which was not dis- 
covered until after death, the fragments not being at all displaced. 3 

Dr. John Boardman, one of the surgeons to the Buffalo Hospital of 
the Sisters of Charity, informs me that he has met with a fracture of 
the zygoma in a man about thirty years of age, occasioned by a blow 
from a cricket-ball. Dr. Boardman saw him on the fourth day, and 
ascertained that immediately on the receipt of the injury he felt slightly 
stunned, and that he soon recovered from this, but was unable to open 
his mouth except by pulling it open with his hand ; neither could he 
close it except in the same manner. This immobility of the jaw con- 
tinued several days with only very slight improvement; at the end of 
five weeks, however, when last seen, the mobility was nearly, but not 
quite, restored. The depression, a little in front of the centre of the 
zygoma, was discovered by the patient himself immediately after the 
receipt of the injury, and he says he tried at once to ascertain whether 
he could not push the fragments back by moving the jaw. He was 
unable to make any impression upon them by this manoeuvre. The de- 
pression still remains, but it is not so distinct as it was when first seen. 

Barney Quinn, presented himself at the Bellevue Dispensary, April 
17, 1871, stating that he had been hit by a stone, in blasting, three 
weeks before. There was a fracture, with depression, at or near the 
junction of the malar and temporal processes.. The malar bone was 
elevated a little. From the time of the accident he had been unable to 
open his mouth more than half an inch. 

January 2, 1874, Anna McQuirk fell upon the side of her face. 
Seven days after the accident she consulted me. There was a fracture 

1 Injuries and Diseases of Bones, by Baron Dupuytren. Syd. ed., London, 1847, 
p. 33G. 

2 Op. cit., p. 335. 

3 Bulletin de la Soc. Anat., 1810, p. 138. 



FRACTURES OF THE ZYGOMATIC ARCH. 109 

with depression at the junction of the malar bone with the zygoma. 
At first, and for a day or two, she could open and close her mouth 
easily, but when I saw her, the act of opening the mouth was painful 
and difficult. Having introduced my fingers into the mouth, I at- 
tempted to press the fragment out, but was unable to make any impres- 
sion upon it. 

It is plain that in this latter case, the inability to open the mouth 
was due to the inflammation resulting from the injury and not to the 
displacement of the bone, and that as the inflammation subsided the 
disability would disappear. 

Symptoms. — An irregular projection or depression of the fragments 
is the only sign which can be relied upon to indicate the existence of 
this accident; and this must often be concealed by the swelling which 
follows so rapidly wherever the integuments are severely bruised over 
a superficial bone. This displacement can scarcely occur in but two 
directions, either outwards or inwards; since the attachments of the 
temporal aponeurosis above, and of the masseter muscle below, must 
effectually prevent its descent or ascent. 

Xeither motion nor crepitus will often be present. In some few cases 
the difficulty in opening or shutting the mouth, occasioned by the pro- 
jection of the fragments toward or into the tendon of the temporal 
muscle, may assist in the diagnosis. 

Prognosis. — If the fracture has been produced indirectly by a de- 
pression of the malar bone, the prognosis must depend upon the amount 
of injury done to the other bones of the face; in itself, the fracture of 
the zygoma cannot be a matter of any moment. The same remark 
might apply also to any fracture of the zygoma in which the angles 
were salient outwards. If, on the contrary, the angle is salient inwards, 
the fracture having been produced by a blow inflicted directly upon the 
zygomatic arch from without, or by a blow upon the outer portion of 
the malar bone, it may, perhaps, occasion some embarrassment to the 
action of the temporal muscles. 

If the force which produces the fracture has acted more upon the 
temporal portion of the arch, near where the process arises from the 
temporal bone, it may be accompanied with a fracture of the skull, and 
with serious cerebral lesions, as in one of the cases already alluded to as 
having been noticed by Dupuytren. 

The abscess which followed in the case of the compound, commi- 
nuted fracture, quoted from the same author, indicates the danger of 
this complication ; but it must be noticed that its evacuation resulted 
in a rapid cure, and that no deformity or difficulty in moving the jaw 
remained. 

Treatment. — A fracture, accompanied with an outward displacement, 
and occasioned by a depression of the malar bone, will be adjusted by 
a restoration of the malar bone in the manner already described, when 
speaking of fractures of the superior maxilla, etc. If the fragments 
are displaced outwards, in consequence of a direct blow from within, 
then they may be replaced by pressing upon the projecting angle. 
In this way Duverney easily reduced the bones in the case which I 
have cited. 



110 FRACTURES OF THE ZYGOMATIC ARCH. 

When the fragments, in consequence of a direct blow from without, 
have been driven inwards, and, as a consequence, serious embarrass- 
ment to the motions of the temporal muscle ensues, an attempt ought 
to be made at once to replace them ; if, however, no impediment to the 
action of the muscle exists, it is scarcely necessary to say that no surgi- 
cal interference will be required. It is quite probable, indeed, that a 
slight amount of embarrassment may be the result of the direct injury 
to the muscle inflicted by the blow, without reference to the displace- 
ment of the bone, and that a few days will suffice to remedy this evil 
entirely ; and, moreover, experience teaches that in the case of a frac- 
ture in other bones, where the fragments actually penetrate the muscles 
and remain thus displaced, the points are gradually absorbed, and 
rounded, so that after a time they constitute no impediment to the 
action of the muscles. It is proper to infer that the same thing will 
occur here. The surgeon may be reminded, also, that it is not the 
muscle but its tendon which is liable to be penetrated; and that this is 
usually protected, somewhat, by a plate of soft adipose tissue lying be- 
tween the tendon and the arch. 

If to these considerations we add the difficulties which we shall be 
likely to encounter in the reduction, we shall expect to find but few 
cases in which a resort to surgical interference will be necessary. 

Duverney says that he restored a fracture of this arch, accompanied 
with depression, by pressing against the zygoma from within the mouth ; 
but an examination of the interior of the buccal cavity will convince us 
that this is impossible when the fracture is at any point near the middle 
of the zygoma ; and that it can be only when the fracture is at or near 
the junction of the zygoma with the body of the malar bone, that any 
effective pressure can be made from this direction. In such a case, we 
may, perhaps, lift the portion of the zygoma remaining attached to the 
malar bone, by the same means which have already been suggested for 
lifting the bone itself. 

If the bone is driven toward the tendon of the temporal muscle at or 
near its centre, as happens almost always, then if its restoration be- 
comes necessary, it can be accomplished only by approaching the bone 
from without. 

Dupuytren found an external wound through which, by the aid of a 
levator, he easily restored the fragments to place. 

M. Terrier, however, of the Hospital of Aries, in a case brought 
before him, made an incision through the integuments down to the 
bone, and then attempted to slide underneath the small extremity of a 
spatula ; but the aponeurosis would not yield, and he was obliged to 
cut it also. He was now able to lift the fragments easily. The wound 
healed rapidly, and the patient was dismissed without any deformity. 1 

1 Bulletin des Sciences Med., torn, x, p. 160. 



FRACTURES OF THE LOWER JAW. Ill 




CHAPTEE XII. 

FKACTUKES OF THE LOWEK JAW. 

Division. — Of 45 examples of fracture of this bone which have been 
recorded by me, not including gunshot fractures, 42 were broken 
through some portion of the body. 

Having made an analysis of 35 of the above examples, I find that 
13 were broken completely asunder at two or more points, constituting 
double and triple fractures ; and of the remaining 22, 5 were accom- 
panied with detachment of portions 
of the alveoli, and 1 with detach- fig. 27. 

ment of a considerable fragment 
from the body. 

19 of the 35 were comminuted 
fractures. 12 were compound; not 
including in this enumeration sev- 
eral examples in which the partial 
or complete dislodgment of a tooth 
might entitle them to be called 
compound. 

Four fractures through or near 
the symphysis were nearly or quite vertical, and 20 of the remainder 
were known to be oblique. Malgaigne has remarked, also, that in 
fractures of the body of the bone the direction of the obliquity is 
generally such that the anterior fragment is made at the expense of 
the internal face of the bone, and the posterior fragment at the expense 
of the external face ; this latter overriding the former. Buck, of New 
York, has seen the fragments in an opposite condition, requiring the 
use of the knife and the saw for their extrication. 1 I have myself 
recorded one similar example, but in which the fragments were easily 
replaced. 

In 22 examples of fractures through the body, not including frac- 
tures of the symphysis, the line of fracture has been observed to be 15 
times at or very near the mental foramen, twice between the first and 
second incisors, three times behind the last molar, and twice between 
the last two molars. 

Syme, Liston, and Miller have remarked, also, the greater frequency 
of fracture near the anterior mental foramen; but Mr. Erichsen thinks 
he has seen it most frequently broken near the symphysis, between the 
lateral incisors, or between these teeth and the canine. Boyer observes 
that it is generally somewhat in front of the foramen ; for which reason, 
as he thinks, the dental nerve is rarely torn. 

1 New York Journ. Med., March, 1847. Proceedings of N. Y. Med. and Surg. 
Soc, Sept. 19, 1846. 



112 FRACTUKES OF THE LOWER JAW. 

Says Boyer, in his Traite des Maladies Chirurgicales, " A fracture 
never takes place in the central point of the length of the jaw, called 
the symphysis of the chin ; but when the solution of continuity occurs 
toward the middle of the bone, it is upon one or the other side of the 
symphysis, which remains always upon one of the fragments." An 
opinion which, however, he does not seem always to have entertained, 
since Richerand, in a report of his lectures, has made him say that a 
fracture sometimes takes place "near the chin, but seldom so as to 
produce the division of the symphysis of that part, though it be not 
impossible." But many surgeons since his time have noticed this 
fracture, and Malgaigne assures us that J. Cloquet has demonstrated 
its existence upon an anatomical specimen. 

Stephen Smith, of New York, has seen two examples, 1 Lonsdale men- 
tions three, 2 and Gibson has seen one, 3 and I have met with two, both 
of which are recorded in the early editions of this book. 

Velpeau, Fergusson, Gibson, Henry Smith, and others, have re- 
marked that a separation at the symphysis takes place usually in in- 
fancy or childhood. But in the eight examples in which I find the 
ages reported, only one, a case mentioned by Lonsdale, occurred in a 
person as young as ten years ; in one of the cases seen by myself the 
patient was seventeen years old, and the remainder have ranged from 
twenty-five years to sixty ; and the average age of all is thirty-two 
years. 

I have seen one example of a fracture of the ramus, in a man twenty- 
three years old, who had been struck by a wooden block on the side of 
his face. The ramus was broken just above the angle, and the body 
was broken, also, obliquely near the symphysis. The intercepted frag- 
ment was carried inwards; 4 and in May, 1869, I met with another 
similar case at Bellevue Hospital, in a woman ; a pharyngeal abscess 
resulted, threatening suffocation ; for which my house surgeon, Dr. 
Frank Bosworth, performed tracheotomy successfully. Ledran men- 
tions the case of a child, ten or twelve years old, in whom the fracture 
was double also ; one fracture having taken place through the body, 
and one extending obliquely from the root of the coronoid process to 
the neck of the condyle. The intercepted fragment was, however, so 
little displaced that the fracture of the ramus was not discovered until 
after death. 5 Malgaigne refers to this as the only example recorded ; 
but Stephen Smith, of the Bellevue Hospital, has met with it four times : 
in one case the ramus was broken on both sides ; in two cases one ramus 
only was broken ; and in one the body was broken on the right side 
and the ramus on the left. 6 In two of these examples the fragments 
were not displaced. 

1 New York Journ. Med., Jan. 1857, Hospital Reports. 

2 Practical Treatise on Fractures. By Edward F. Lonsdale. London, 1838, p. 226. 

3 Institutes and Practice of Surg. By William Gibson. Philadelphia, 1841, p. 
261. 

* Trans. Amer. Med. Assoc. Report on " Deformities after Fractures," vol. viii, 
p. 385, Case 17. 

5 Malgaigne, op. cit., p. 337, from Ledran, Observ. Chiruri; , torn, i, obs. viii. 

6 New York Journ. of Med., Jan. 1857. Bellevue Hosp. Reports. 



FRACTURES OF THE LOWER JAW. 113 

The coronoid process is so well protected by muscles and by the sur- 
rounding bony projections, that it is very rarely broken. 

Houzelot mentions a case in which a fall from a height produced at 
the same time a fracture of both condyles, of both coronoid processes, 
and of the symphysis. 1 

With this single exception, I am not able to find a recorded example 
of a fracture of this process. 

At least nine cases have been reported of fracture of the condyles, in 
all of which the separation occurred through the neck, viz., three by 
Ribes, two by Desault, one by Berard, one by Houzelot, one by Bichat, 
one by Packard, of Philadelphia, and two by Watson, of New York; 
the fracture always occurring through the neck and just below the 
insertion of the external pterygoid muscle. 

According to Malgaigne, the analysis of these cases, excepting those 
mentioned by Packard and Watson, shows two classes of examples ; 
the one occasioned by falls or blows upon the chin, and producing a 
simple fracture of the neck of the condyle; the other occasioned by in- 
juries inflicted upon the side of the face, and producing a fracture of 
the neck on the side corresponding to that upon which the injuries are 
received, and at the same time a fracture of the body upon the opposite 
side. These two varieties seem to be about equally common. 

In the case mentioned by Houzelot, and already cited, there existed 
at the same time a fracture of both condyles, of both coronoid processes, 
and at the symphysis. The man also whom Watson saw in the New 
York Hospital had fallen from the yard-arm of a vessel, breaking his 
thigh and arm bones and both condyles of the lower jaw. " His face was 
somewhat deformed by the retraction of the chin ; the mouth could not 
be opened so as to protrude the tongue to any great extent beyond the 
teeth, and the teeth of the upper and lower jaws could not be brought 
into contact. In attempting to move the jaw, the patient experienced 
pain and crepitation just in front of the ears; the crepitation could 
easily be felt by placing the fingers over the fractured condyles. 
Nothing was done for the fractures of the jaw. In a few weeks the 
rubbing of the broken surfaces and attendant soreness ceased to trouble 
him ; but the shape of the jaw, and difficulty of opening the mouth to 
any great extent, still remained unaltered/' 2 

Etiology. — The causes, in such cases as I have myself investigated, 
seem generally to have been direct blows, in most instances inflicted by 
a club, or by the kick of a horse ; in two examples the blow was in- 
flicted by the fist, I have also seen a fracture immediately in front 
of the right cuspid, in a lad eight years of age, produced by being 
pressed between two wagons, the pressure being made upon the two 
angles of the jaw. In ten of eleven cases mentioned by Stephen Smith, 
the causes were direct blows. Examples of fracture of the inferior 
maxilla from indirect blows have, however, been mentioned by other 
surgeons, the angles of the bone being pressed together by the passage 

1 Malgaigne, op. cit., p. 400. 

2 New York Journ. of Med., Oct. 1840. Hospital Reports. 



114 FRACTURES OF THE LOWER JAW. 

of a wheel, and the fracture taking place usually toward the sym- 
physis. 

We have already alluded to the observation of Malgaigne, that frac- 
tures of the condyles belong to two classes ; the one being occasioned 
by falls upon the chin, and the other by blows upon the side of the 
face ; the former acting as a counter force, and the latter as a direct. 

The coronoid process can only be broken by a direct blow. 

Symptoms. — Fractures of the body of the bone are characterized by 
the usual signs of fracture elsewhere, namely, displacement, mobility, 
crepitus, and pain. 

The displacement is generally present; but its direction and amount 
vary according to the situation and course of the fracture, and also ac- 
cording to the violence and direction of the force producing the frac- 
ture. I have seen several cases unaccompanied with displacement, and 
one of these I think ought to be regarded as an example of a partial 
fracture. 

A lad, set. 9, was kicked by a horse on the 22d of June, 1858, the 
blow being received on the right side of the jaw. I saw him very soon 
after the accident, but could not detect any fracture, only the body of 
the jaw seemed to be bent in. On the third day, however, while en- 
deavoring to straighten the jaw by violent pressure from within out- 
wards, I detected a feeble crepitus, which on more careful examination 
proved to be opposite the second incisor of the right side. I was also 
able to detect a slight motion at the same point. It was found impos- 
sible to rectify the bending, and no farther efforts were employed. 
After the lapse of nearly a year, the natural curve was found to be par- 
tially, but not completely, restored. 

Ledran and other surgeons have also seen examples where neither 
the periosteum nor mucous membrane was torn. 

Generally, in fractures of the body, the anterior fragment is de- 
pressed ; and Malgaigne affirms that where an overlapping occurs, the 
anterior fragment lies, generally, within the posterior; a fact which he 
explains by the direction which the line of fracture usually takes, namely, 
from without, inwards and backwards, as we have already mentioned. 
In one instance, reported by me to the American Medical Association, 
where the jaw was broken at the symphysis and also on both sides 
through the body, the central fragments were found, after about four 
weeks, lifted two lines above the lateral fragments, and also slightly 
carried backwards. 1 I have twiee also met with examples in which 
the posterior fragments were inclined to fall inwards toward the mouth, 
a circumstance which seemed to indicate that the course of the obliquity 
was in a direction opposite to that which Malgaigne has observed to 
be most frequent. In each of these examples the jaw was broken 
upon both sides, by blows inflicted with a club, and the fractures were 
situated well back. 2 It is possible, however, that the position of the 
fragments was due rather to the direction and force of the impression 
than to the direction of the line of fracture. 

1 Trans. Amer. Med. Assoc, vol. viii, p. 380, 1855, Case 6. 

2 Ibid., Cases 1 and 10. 



FRACTURES OF THE LOWER JAW. 115 

As to the action of the muscles in the production of displacement, 
Boyer, S. Cooper, Erichsen, and Malgaigne have observed that their 
action upon the anterior fragment is greater in proportion as the frac- 
ture is nearer the symphysis, and less in proportion as it approaches 
the angle. So that in the former case the attempt to close the mouth 
is sometimes attended with a depression of the anterior fragment, caus- 
ing a separation of the fragments at their alveolar margins; while in 
the latter case the attempt to close the mouth forcibly is occasionally 
attended with separation of the fragments along the line of the base. 

While I am not prepared to deny the accuracy of these observations, 
it is proper to notice that Liston found the greatest displacement when 
the fracture was opposite the first molar; and I must confess that the fact, 
as stated by Boyer and others, does not seem to admit of a satisfactory 
explanation ; since the number, and consequently the power, of the 
muscles which act upon the anterior fragment from below is greater in 
proportion as the line of fracture is farther back. These muscles, 
namely, the digastricus, the genio-hyoglossus, and the mylo-hyoideus, 
with several other muscles which act less directly, all tend to depress 
the anterior fragment, and in some slight degree to carry it backwards; 
a direction which, indeed, it usually takes, and which it would prob- 
ably always take if left alone to the action of the muscles. If the frac- 
ture has occurred through the angle, or at any point within the attach- 
ments of the masseter muscle, the action of those fibres of this muscle 
which remain connected with the anterior fragment will sufficiently ex- 
plain the fact that it is not now so easily depressed below the level of 
the posterior fragment ; while the separation of the fragments along 
the line of the base when an attempt is made to close the jaAV forcibly, 
is probably due to the loosening and partial dislodgment of some of 
the molars, which, being pressed upwards, act as a pivot upon which 
the fragments are made to bend. 

Boyer affirms, also, that " the fractured portions are never deranged 
so as that one passes on the other, or in the direction of their length ; 
for the action of none of the muscles of the lower jaw is parallel to the 
axis of that bone ; besides, its extremities are retained in the glenoidal 
cavities of the temporal bones." But this theory is too exclusive, since 
the fragments may have become displaced in any direction indepen- 
dently of the muscular action. Moreover, the action of the muscles 
attached to the anterior fragment, although not parallel to the axis of 
the bone, does somewhat favor a displacement in this direction ; and 
the action of the pterygoid muscles upon the posterior fragment still 
farther favors this form of displacement. 

An overlapping of the fragments in the direction of the axis is, in 
simple fractures, no doubt, exceptional, and in such examples as I have 
seen, it was very trivial. It occurred in case "three " of my "Report," 
the fracture being near the mental foramen ; in case " two," the frac- 
ture being just anterior to the last molar; and also in case "six," 
where the bone had been broken through the centre of the body on 
both sides and through the symphysis ; but in neither case did the 
overlapping exceed two or three lines, and it was always easily over- 
come. 



116 FRACTURES OF THE LOWER JAW. 

The mobility of the fragments is not so striking in these accidents as 
in fractures of the long bones, yet it is generally sufficiently marked, 
and especially where the bone is broken upon both sides at the same 
time. If only one side is broken, both motion and crepitus will be 
most easily detected by lateral pressure upon the posterior fragment, 
which, being the smallest and the least supported by antagonizing 
muscles, will be found to be the most movable. If the fracture is upon 
both sides, mobility and crepitus will be most readily developed by 
seizing upon the anterior fragment and moving it gently up and down, 
while the ringer rests upon the alveolus within the mouth. 

Sometimes a slight swelling or tenderness at some point of the den- 
tal arcade, or the loosening or complete dislodgment of a tooth, will 
indicate the point of fracture. 

Pain, especially when the fragments are moved, is here more con- 
stant than in most other fractures, owing perhaps, in part, to the super- 
ficial position of the bone, which renders the soft parts lying over it 
more liable to injury from the causes of fracture; but also, in part, to 
the lesions which the inferior dental nerve may have suffered. It is, 
indeed, a matter of surprise that injury to this nerve does not oftener 
seriously complicate these accidents, coursing, as it does, through so 
large a portion of the angle and body of the bone. One might naturally 
suppose that its complete disruption would often occasion paralysis of 
those portions of the face to which it is finally distributed, and that its 
partial lesions and contusions would create, in many cases, the most 
acute and constant suffering. It is rare, however, that we have present 
an amount of pain which might not be attributed to a severe shock, or 
a slight strain upon its fibres. I have myself never seen any extraor- 
dinary suffering distinctly attributable to an injury of the dental nerve 
after fracture ; nor any degree of facial paralysis, except in the case to 
be hereafter described. Rossi relates a case in which convulsions fol- 
lowed this accident, and in which, as a final remedy, he proposed to 
expose and bisect the nerve; and Flajani saw a patient, whose jaw had 
been broken, die in convulsions on the tenth day, the muscular con- 
tractions having commenced as early as the fourth day after the acci- 
dent. The autopsy disclosed a rupture of the dental nerve, but no 
injury to the brain. 

Boyer explained the infrequency of severe injury to the dental nerve 
by the supposition that the " greater part of these fractures take place 
between the symphysis and the foramen by which this nerve comes 
out." An opinion which may be correct, but needs confirmation. I 
have seen the body or angle broken at points posterior to the mental 
foramen, and where the nerve lies within its bony canal, at least thirteen 
times, and in front of the mental foramen nine times ; at other times 
the point of fracture has not been noted with such accuracy as to enable 
me to say whether it was in front or behind the foramen. 

I suspect that a better explanation may be found in the fact that the 
fragments seldom overlap, to any appreciable extent, and that even the 
displacement in the direction of the diameters of the bone is generally 
inconsiderable ; or if it does exist, the fragments are easily and promptly 
replaced. 



FRACTURES OF THE LOWER JAW. 117 

If the displacement is sufficient to occasion a complete disruption of 
the nerve, some degree of temporary paralysis in the portions of the 
face supplied by it must be inevitable ; and, perhaps, this occurs oftener 
than it has been noticed, since, during the confinement of the jaw by 
dressings, it is not likely to be observed, and after the lapse of a few 
weeks it will probably cease altogether. 

Boyer remarks that when it is torn, "the square and triangular 
muscles of the chin are paralyzed. The skin of that part and the in- 
ternal membrane of the under lip preserve their sensibility, which it 
appears they owe to some threads of the portio dura of the seventh 
pair ; but the paralysis of these muscles does not prove of itself that 
the jaw is fractured." Boyer has, however, noticed this result but 
once, and then in a case where the bone was broken upon both sides 
and the soft parts greatly contused. The triangular and square muscles 
were paralyzed, in consequence of which there was a slight contortion 
of the mouth. A. Berard has also mentioned a case of vertical frac- 
ture occurring between the second and third molars, without displace- 
ment, which was accompanied with complete insensibility of the lip on 
the same side throughout the space comprised between the commissure 
and the median line, and between the free border of the lip and the 
chin. The paralysis disappeared after a few days. 1 

At my request, Dr. Frederick S. Dennis, junior assistant at Belle- 
vue Hospital, has furnished me with the following account of a case 
lately presented in one of my wards. I shall take the liberty of con- 
densing somewhat the very full and interesting history which he has 
furnished me; remarking, however, that the observations are all the 
result of his own careful investigation. 

Kate Campbell, set. 30, was admitted, December 11, 1874, suffering 
from an attack of acute tonsillitis. I subsequently opened an abscess 
in the tonsil, and she was soon discharged cured. While taking notes 
of her case, Dr. Dennis learned the following facts. More than a year 
before she had received a fracture of the lower jaw, right side, and 
a distinct callus remained near the angle of the jaw to indicate the 
point at which the fracture had occurred. Since that time there has 
existed complete insensibility of that portion of the face which is sup- 
plied by the inferior dental nerve and its branches. Careful experi- 
ments were made with different substances, and with sharp instruments, 
all of which indicated "that the nerve was destroyed in the immediate 
vicinity of the dental foramen. The gustatory nerve, as well as the 
chorda tympani from the facial, maintained their full physiological 
functions, both in reference to general sensation, and the special sense 
of taste. The mylo-hyoid branch of the inferior dental, which is given 
off just before the nerve enters the dental foramen, and which is motor 
in action, was not in the least impaired." Over the entire region 
supplied by the inferior dental nerve there was complete anaesthesia. 
Pins, thrust through the integument into the buccal cavity, caused no 
sensation. " The gums as well as the teeth, on the side corresponding 
to the fracture, were in a state of analgesia." 

1 Malgaigne, from Gazette des Hopitaux, 10 Auftt, 1841. 



118 FRACTURES OF THE LOWER JAW. 

The case above described furnishes an example of permanent paral- 
ysis of the inferior dental nerve, from fracture ; and upon this point 
the following; comments, made by Dr. Dennis, are of special interest: 

" Haemorrhage into the dental canal, or a slight laceration of the 
inferior dental nerve, with little displacement of the fragments, may 
cause a paralysis, which, in the former case after absorption, and in the 
latter case after repair of nerve-tissues, eventually terminates in com- 
plete recovery ;* but in the case under consideration there is no hope of 
the restoration of the function of the nerve, as too long a time has 
intervened, according to the views of the most sanguine neurologists. 

" Malgaigne has never seen a case of total destruction of the inferior 
dental nerve, in which permanent paralysis followed, from a fracture of 
the lower jaw. He believes the severe pain, which frequently occurs, 
to be due to cerebritis rather than to injury of this particular nerve. 
He further states, in his work on Fractures, that the cases in which 
the nerve is injured, even in a slight degree, are very rare. 

" Petit, Rossi, Flajani, Foucher, Robert, and many other w T riters on 
this subject, give examples where the paralysis was of short duration ; 
and they say that they have never seen a case where the paralysis re- 
mained permanent. The only case that can be found, in the researches 
that have been made, where the paralysis was permanent, is one re- 
ported by Desirabode in the Journ. des Connaissances, 1857, No. 20, 
p. 538 ; and in this case the symptoms of injury of the inferior dental 
nerve are identical with those found in the case of Kate Campbell. 
The paralysis, in the case which Desirabode reports, was caused by a 
crude dental instrument, which tore the alveolar processes of seven 
teeth, and exposed the dental canal." 

To these signs now enumerated, we may add as occasional compli- 
cations, rather than as diagnostic symptoms, salivation, swelling of the 
submaxillary and sublingual glands, abscesses, necrosis, etc. If the 
blow has been vertical upon the chin, and the direction of its force has 
been toward the articulations, the bony structure of the ear, and even 
the brain, may have suifered serious lesions, which may be indicated 
by a deafness or a roaring in the ears, by bleeding from the external 
meatus, and by fatal coma. Tessier saw a man who had received the 
kick of a horse exactly upon the centre of the chin, breaking the bone 
on both sides, and who, in consequence, bled freely from his ears j 1 and 
Alix relates the case of a young man who, falling from a height and 
striking upon his chin, had broken his jaw. Insensibility immediately 
followed ; convulsions also ensued upon the fourth day, and he died 
upon the sixth. 2 

If the fracture is at the symphysis, it is generally vertical, and either 
fragment may be found slightly displaced upwards or downwards. In 
one of the examples seen by myself, the left fragment fell three lines 
below the right, and in another the right side had fallen about one line. 
In a case mentioned by Syme there was scarcely any displacement. 3 

1 Malgaigne, pp. 383 and 386, from Journ. de Med., 1789, torn, lxxix, p. 246. 

2 Ibid., p. 386, from Alix, Observata Chir , fascic. 1, obs. 10. 

3 Amer. Journ. Med. Sci., vol xviii, p. 243. 



FRACTURES OF THE LOWER JAW. 119 

Liston remarks that it is usually slight. Erichsen and B. Cooper 
have observed the same. 

The signs which indicate a fracture through the angle have already 
been sufficiently considered when speaking of fractures of the body ; 
from which it only differs in the less degree of displacement, and in 
the fact that the posterior fragments are a little more prone to fall in- 
wards toward the mouth. I have noticed, also, that, owing probably 
to the loosening and partial dislodgment of the last molar, it is some- 
times difficult to close the mouth, the same as in the fractures a little 
farther forwards. 

In each of the two examples of fracture of the ascending "ramus 
which I have seen, the bone being broken also through its body, the 
fracture of the ramus was recognized by both crepitus and mobility. 

As to the signs which indicate a fracture of the coronoid process, I 
am only able to infer them from its anatomical relations. There must 
be some embarrassment in the motions of the jaw, occasioned by the 
detachment of a portion of the fibres of the temporal muscle; and it is 
probable that an examination by the finger within the mouth would 
readily detect mobility and displacement. 

A fracture through the neck of the condyle is characterized by pain 
at the seat of fracture, especially recognized when an attempt is made 
to open or shut the mouth, by embarrassment in the motions of the 
jaw, by crepitus, which may usually be felt or heard by the patient 
himself, by mobility and displacement. 

The upper fragment, if disengaged from the lower, is drawn forwards, 
upwards, and inwards, by the action of the pterygoideus externus; and 
it is felt not to accompany the movements of the lower fragment. 

The lower fragment is at the same time drawn upwards, in conse- 
quence of which the lower part of the face is distorted ; a circumstance 
first noticed by Ribes, and which supplies an important diagnostic 
mark between a fracture of one condyle and a dislocation. In dislo- 
cation, the chin is commonly thrown to one side, but it is to the side 
opposite that on which the dislocation has occurred, while in fracture 
the chin is drawn to the same side. 

Prognosis. — Physick, of Philadelphia, saw a case of non-union of 
the body of this bone, which had existed nine months. 1 Dupuytren 
mentions a case which had existed three years. 2 Stephen Smith, of 
New York, reports a case of fracture of both the body and the ramus, 
in a man forty-five years old. The severity of the injury, with the 
supervention of delirium tremens, prevented the application of dress- 
ings until the thirteenth day. On the twentieth day, about a pint of 
blood w r as lost by hemorrhage from the seat of fracture. He re- 
mained in the hospital one hundred and thirty-seven days, and was 
finally discharged, the fragments not having yet united. 3 I have seen 
one example of fibrous union in the case of a man who broke the body 
of the jaw by a fall upon his chin. Malgaigne says that Boyer has 
seen several examples, but I know of no other cases, unless as the 

1 Phila. Med. and Surg. Journ., vol. v. 2 Lecons Orales. 

3 Smith, New York Journ. of Med. and Surg., Jan. 1857. 



120 FRACTURES OF THE LOWER JAW. 

result of gunshot injuries, which have been recorded. In no instance 
of a simple fracture which has come under my personal care, has the 
bone refused finally to unite, although I have seen the union delayed 
six, seven, ten, and even eleven weeks or more. 1 In three of these 
cases the fractures were either compound or comminuted ; but in one 
case the fracture was simple, the delay in the union being due to a feeble 
condition of the system, and in part, perhaps, to neglect of proper 
treatment. Since the commencement of the late war I have met with 
several examples of non-union, and of fibrous union, after gunshot 
fractures ; but, so far as I can remember, in all of these cases necrosis 
existed, or some portions of the bone had been carried away. 

The infrequency of non-union after this fracture is a fact worthy of 
especial attention, because of the extreme difficulty, if not actual im- 
possibility, in many cases, of wholly preventing motion between the 
fragments, by any mode of dressing yet devised. Any one who has 
observed attentively, must have seen, not only that his dressings are 
more often found disturbed and loosened than in the case of almost any 
other fracture, unless it be the clavicle, and thus the fragments have 
been through all the treatment subjected to frequent changes of posi- 
tion ; but, also, that even while the dressings remain snugly in place, 
the patient seldom is able to perform the necessary acts of deglutition, 
or to speak, even, without inflicting some slight motion upon the frag- 
ments. 

Indeed, the rapidity as well as certainty with which this bone unites, 
has, I think, been observed by other surgeons, and I have myself no- 
ticed one instance, in an adult person, in which the bone was immova- 
ble at the seat of fracture on the seventeenth day, and perhaps earlier. 
In other instances, the union has been speedily effected after the re- 
moval of all dressings. 

The amount of deformity resulting, also, from these fractures is 
usually very trifling, whatever treatment has been adopted. Only 
nine of the united fractures, seen and recorded by me, are imperfect, 
and in none of these is the imperfection such as to be noticed in a casual 
examination of the face. The deformity which is usually found, is a 
slight irregularity of the teeth, produced, in most cases, by a falling of 
the anterior fragment, but in one case by a slight elevation of the an- 
terior fragment. But even this does not always interfere with masti- 
cation, and would often pass unnoticed by the patient himself. It is 
probable, too, that time, and the constant use of the lower jaw in mas- 
tication, will gradually effect a marked improvement in the ability to 
bring the opposing teeth into contact. I think I have observed this 
in several- instances. 

Chelius remarks that in "double or oblique fractures it is very diffi- 
cult to keep the broken ends in their proper place; deformity and dis- 
placement of the natural position of the teeth commonly remain/' 

In the second example of fracture through the symphysis mentioned 
by me, the left fragment remained slightly elevated, and the patient 
could not close his teeth perfectly, yet he could close them sufficiently 

1 My Report on Deformities after Fractures, Cases 2, 14, 15, 18. 



FRACTURES OF THE LOWER JAW. 121 

for the purposes of mastication. It is probable, however, that ordina- 
rily no difficulty will be experienced in accomplishing a perfect cure 
when the separation has taken place only at the symphysis. 

In fractures of the condyles, more care is requisite to retain the frag- 
ments in apposition, and sometimes it may be found to be impossible. 
Eicherand mentions the case of a man, who, having been three months 
in the " Hopital de la Charite," for a double fracture of the lower jaw, 
one fracture being near the middle, and the other near the right con- 
dyle, left before the cure was complete. Seven or eight months after, 
he called upon Boyer, who extracted from a fistula in the meatus audi- 
torius externus, a bony mass which had evidently the form of the con- 
dyle. 1 Bichat mentions a similar case as having come under the ob- 
servation of Desault; 2 possibly it was the same which Boyer saw. 
Ribes says that a Parisian surgeon treated a double fracture of the jaw 
in a gentleman, one fracture being through the body and the other 
through the neck of the condyle; and, in spite of the most assiduous 
and skilful attention, the patient recovered with a lateral distortion of 
the jaw, occasioned by the displacement of the fragments. 3 Ribes him- 
self had to treat an accident of a similar character, and, notwithstand- 
ing all his care, the result was the same as in the other example just 
cited. 4 Fountain, of Iowa, was much more fortunate, having made a 
complete and perfect cure. 5 

The proximity of this fracture to the articulating surface may occa- 
sion contraction of the ligaments about the joint; and a degree of em- 
barrassment to the motions of the jaw has followed in the experience 
of Desault and others, even when the cure has been most complete ; 
but this has usually remained only for a short period. 

Sanson asserts that when the coronoid process is broken, the fracture 
never unites ; but that mastication is performed very well, the masseter 
and pterygoid muscles then fulfilling the office of the temporal. 6 

Treatment. — The few attempts which I have made to restore a com- 
pletely dislocated tooth to its socket, or to retain it in place when very 
much loosened, have generally resulted in its removal at some later 
day, and especially where the fracture has been near the angle and a 
molar has been disturbed. I believe it would be better practice always 
to remove the molars under these circumstances, unless they remain 
attached to the alveoli, and cannot be removed without bringing them 
away also; and this, whether the loosened teeth are situated in the 
line of fracture or not. It is seldom that they can be made again to 
occupy their sockets perfectly, and where the teeth are in the line of 
the fracture, the attempt to restore them to place will sometimes pre- 
vent the proper adjustment of the fragments. In cases, also, in which, 
the teeth farther forwards are completely dislodged at the seat of frac- 
ture, it is scarcely worth while to replace them. 

1 Boyer, Lectures on Dis. of Bones, p. 53, Phi la. ed., 1805. 

2 Desault, Treatise on Fractures and Luxations, Phila. ed., 1805, p. 3. 

3 Malgaigne, op. cit., p. 40-'. 
< I hid . , p. 402 

5 Fountain, New York Jour. Med., Jan. 1860. 

6 S. Cooper's First Lines, Amer. ed., 1844, vol. ii, p. 311. 

9 



122 FRACTURES OF THE LOWER JAW. 

As to those teeth whose loosened condition is due only to a splitting 
of the alveoli in a longitudinal direction, the same rule will not always 
apply. Sometimes, after a careful readjustment, the fragments will re- 
unite, and the teeth remain firm. 

If the bone is chipped off upon the outside, through or near the line 
of the sockets, the teeth may not be always much disturbed, and the 
loss of the fragments may be of less consequence, nor have I generally 
succeeded in saving them ; yet if they remain adherent to the soft parts, 
it is proper to make the attempt. 

The expedients to which surgeons have resorted for the purpose of 
retaining in place the fragments, when the bone is broken through its 
body, may be arranged under the names of ligatures, splints, bandages, 
and slings. 

The ligature has been applied both to the teeth and to the bone itself. 
Thus, in an oblique fracture near the angle, where the fragments 
could not otherwise be prevented from falling inwards, Baudens passed 
a strong ligature, formed of thread, around the fragments and in im- 
mediate contact with them, tying the ligature over the teeth within the 
mouth. No accident followed, and on the twenty-third day, when he 
removed the ligature, the bone had united firmly and smoothly. 1 

In the case of the fracture of the inferior maxilla, reported by Dr. 
Buck to the New York Pathological Society, and already referred to, 
the bone " was broken between the two incisor teeth of the left side ; 
the part of the bone on the left of the fracture was driven in, and in- 
terlocked behind the end of the right portion, so as to be separated by 
a finger's breadth. Finding it impossible otherwise to reduce the frac- 
ture, Dr. B. dissected off the under lip, so as to expose the fracture. 
He found that the right anterior portion of the fractured bone termi- 
nated in an angular projection as far as on a line below the left angle 
of the mouth. The lip was then divided to the chin, and the soft parts 
holding the fragments together incised. A chisel was then insinuated 
behind the projecting angle of the bone, while it was being excised 
by the metacarpal saw. When the bone was restored to its natural 
position, it was found so apt to become displaced, that holes were drilled 
at the lower angle of the fracture, and adjustment maintained by wiring 
them together, the wire passing out through the lower angle of the 
wound. Sutures and adhesive straps, with a bandage, were employed 
to maintain the adjustment of the parts. So far the patient has done 
well, being supported by liquid nourishment introduced through a tube 
passed through the space left by one of the incisors, which, on account 
of its looseness, was removed." 2 Dr. B,. A. Kinloch, of Charleston, 
S. C, has reported a similar case, in which he employed successfully 
the wire. 3 

In May, 1858, while trephining at the angle of the jaw for the pur- 
pose of cutting out a portion of the dental nerve in a patient suffering 
from neuralgia, I accidentally broke the jaw in two at the point at 
which the trephine was applied. I immediately bored a hole in the 

1 Malgai^ne, op. cit, p. 398. 

2 New York Journ. of Med., etc., March, 1847, p. 211. 

3 Kinloch, Am. Journ. Med. Sci., July, 1859, p. 67. 



FRACTURES OF THE LOWER JAW. 123 

opposite extremities of the two fragments, and fastened them together 
with a silver wire, by which I was able to maintain complete appo- 
sition, and in three weeks the union was accomplished, the wire separat- 
ing and falling out of itself. No splints were ever used. 1 

With these exceptions, so far as I am aware, the ligature has been 
employed as a means of retention only, by fastening it upon the teeth, 
either upon those which are situated on the opposite sides of the frac- 
ture, or upon others a little more remote, or upon the corresponding 
teeth of the upper jaw T , or upon the teeth on the opposite sides of the 
same jaw. 

Ordinarily the ligature, composed of either fine gold, platinum, or 
silver wire, or of firm silk or linen threads — (Celsus advised the use of 
horsehair) — has been applied to the two teeth on the opposite sides of 
the fracture, or if these have not been sufficiently firm, to the next 
teeth. This practice, recommended first by Hippocrates, has received 
the occasional sanction of Ryff, Walner, Chelius, Lizars, Erichsen, 
Miller, B. Cooper, Skey, and others, but by Boyer, Gibson, and Mal- 
gaigne it has been disapproved. 

Dr. S. G. Ellis, of New York, as we have already seen, has treated 
a fracture, occurring through the symphysis, in an adult, by placing 
the mainspring of a watch within the dental arcade, and securing it in 
place with silver wire. The mouth was kept closed by bandages car- 
ried under the chin. The fragments united with only a slight vertical 
displacement. 2 

Dr. George Hay ward, of Boston, surgeon to the Massachusetts Gen- 
eral Hospital, says : " When the bone is not comminuted and there 
are teeth on each side of the fracture, the ends of the bone can be kept 
in exact apposition by passing a silver wire or strong thread aroun(J 
these teeth and tying it tightly. In several cases of fracture of the 
jaw, in which the bone was broken in one place only, I have, in the 
course of the last few years, adopted this practice with entire success, 
and without the aid of any other means. It will be found very useful, 
also as an auxiliary, in more severe cases, in which it may be required 
to use splints and bandages, or to insert a piece of cork between the 
jaws, as recommended by Delpech. It requires some mechanical dex- 
terity to apply the thread neatly ; but in large cities we can avail our- 
selves of the skill of dentists for this purpose/" 3 I have myself in two 
or three instances used a linen thread with excellent results. 

Guillaume de Salicet advises to secure with a silk thread, at the 
same moment, the teeth belonging to the two fragments, and the cor- 
responding teeth of the upper jaw ; 4 while the dentist Lemaire, being 
applied to by Dupuytren to secure in place the ununited fragments of 
a broken jaw, fastened the two left canine teeth to each other by a wire 
of platinum, as had been already suggested by Guillaume de Salicet; 
to these he added two other modes of ligature which were altogether 

1 Buffalo Med. Journ., vol. xiv, p. 148. 

2 Trans. Amer. Med. Assoc. My report on " Defor.," etc., vol. viii, p. 383, 
Case 14. 

3 Boston Med. and Surg. Journ., vol. xix, p. 133, 1838. 

4 Malgaigne, op. cit., p. 392. 



124 FRACTURES OF THE LOWER JAW. 

original. One wire, made fast to the last molar upon one side trav- 
ersed the mouth and was secured to one of the bicuspids upon the 
opposite side ; the other was stretched from the first inferior bicuspid 
on the right to the first superior bicuspid on the left. A cure was ac- 
complished at the end of two months, but one of the wires had nearly 
bisected the tongue; and as it had gradually become imbedded, the 
flesh had closed over it until it rested like a seton through the middle 
of the tongue. 1 

None of these various methods, however, will in general be found to 
possess much value ; for besides that they are all of them, in a large 
majority of cases, wholly unnecessary, and in other cases, owing to the 
absence of the teeth, or to their loosened or decayed condition, or to 
the closeness with which they are set against each other, absolutely im- 
possible, it must be seen, also, that they will generally prove feeble 
and inefficient. The wires act only upon the upper extremity of the 
line of fracture, leaving its lower portions liable to be disturbed by 
trivial causes ; they tend gradually to loosen even the firm teeth which 
they embrace, and not unfrequently, after having been made fast with 
much labor, they soon become disarranged or break. They require, 
therefore, almost always the additional protection afforded by bandages, 
interdental splints, etc. Alone they are usually insufficient, and if 
properly constructed bandages, slings, interdental splints, etc., are em- 
ployed, they are not needed. Sometimes, moreover, they are actually 
mischievous, as when they loosen a sound tooth or press upon and in- 
flame the gums. A. Berard passed a silver wire twice around the 
necks of two adjoining teeth on the opposite sides of a fracture. It re- 
tained the fragments perfectly in apposition during several days ; but 
soon the gums swelled and became painful ; the teeth loosened, and it 
was found necessary to remove the wire. Chassaignac sought to avoid 
these evils by placing the wire upon the middle of the crown, free from 
the gums, and by including four teeth instead of two. A waxed linen 
thread was made fast in this manner, in a case of simple fracture, on 
the seventh day. On the following morning the thread was found 
broken. He applied then a silk ligature in the same manner. On 
about the third day this also was disarranged; the ligatures were now 
discontinued until the eighteenth day, when he renewed the experi- 
ment with a piece of gold wire. Fourteen days after this the ligature 
remained firm, but the gums were red and bleeding. The patient not 
having again returned to Chassaignac, the result is not known. 2 

As to the method suggested by Guillaume de Salicet, it presents no 
advantages to compensate for its inconveniences; while that actually 
practiced by the dentist Lemaire, successful indeed, threatened to sub- 
stitute a loss of the tongue for an ununited fracture of the jaw. 

Splints have been employed in various ways. First, simply interden- 
tal splints, laid along the crowns of the teeth, and only sufficiently 
grooved to be easily retained in place; second, clasps, which are applied 
over the crowns and sides of the teeth, operating chiefly by their lateral 

1 Journ. Univer. des Sci. Med., torn, xix, p. 77. 

2 Lond. Med. and Phys. Journ., .Nov. 1822, p. 401. 



FRACTURES OF THE LOWER JAW. 125 

pressure, or made fast by screws ; third, splints applied to the outer and 
inferior margin of the jaw; fourth, interdental splints combined with 
outside splints. 

Interdental splints have been recommended by many surgeons from 
an early day, and they continue to be employed occasionally up to this 
moment. 

Boyer advises the use of cork splints, placed one on each side be- 
tween the upper and lower jaws, in a few exceptional cases. Miller 
recommends the same in all cases, the "two edges of cork sloping 
gently backwards, with their upper and under surfaces grooved for the 
reception of the upper and lower teeth." Fergusson also has usually 
adopted the same practice. Muys and Bertrandi employed ivory 
wedges. 1 

On the other hand, interdental splints are rejected entirely by Syme, 
Chelius, Skey, Erichsen, and Gibson. 

The objections which have been stated to their use are : that they are 
unsteady and become easily loosened and disarranged ; that they occa- 
sionally press painfully upon the inside of the cheeks ; that they accu- 
mulate about themselves an offensive sordes ; and finally that they are 
unnecessary, since experience has proven, says Gibson, that " there is 
always sufficient space between the teeth to enable the patient to im- 
bibe broth or any other thin fluid placed between the teeth." 

It is not strictly true, however, that in all cases there will be found 
sufficient space between the teeth, when the mouth is closed, for the 
imbibition of nutrient fluids. I have myself seen exceptions ; and in 
such a case the patient, if the mouth were closed in the usual way, 
would have to be fed through a tube conveyed along the nostrils into 
the stomach, as suggested by both Samuel and Bransby Cooper in cer- 
tain bad compound fractures, or through an opening made by the ex- 
traction of one of the front teeth ; neither of which methods ought to 
be preferred to the interdental splints ; but then the separation of the 
front teeth for the purpose of receiving food, is by no means the only 
object to be gained by their use, nor indeed the principal object. Their 
great purpose is to act as splints whenever the absence of teeth, either 
in the upper or lower jaw, renders the two corresponding arcades un- 
equal and irregular, and prevents our making use of the upper as a 
kind of internal splint for the lower jaw. 

It is with a view to the accomplishment of this important end that 
they are often valuable, and ought sometimes to be considered as indis- 
pensable. I believe, also, that many of the inconveniences which have 
been found to attend the use of cork or wood, are obviated by the sub- 
stitution of gutta percha in the manner which I recommended to the 
profession in 1849, 2 and also again in my report to the American 
Medical Association, made in the year 1855. 

The mode of preparing gutta percha, and of adapting it between the 
teeth, is as follows : Dip a couple of pieces of the gum, of a proper 
size, into hot water, and when they are softened, mould them into 

1 Lond. Med.-Chir. Rev., vol. xx, p. 470. 

2 Buffalo Med. and Surg. Journ., vol. v, p. 144, Aug. 1849. 



126 FRACTURES OF THE LOWER JAW. 

wedge-shaped blocks, and carry them to their appropriate places be- 
tween the back teeth on each side of the mouth ; taking care, of course, 
that on the fractured side the splint extends sufficiently far forwards to 
traverse thoroughly the line of fracture. Now press up each horizontal 
ramus of the jaw until the mouth is sufficiently closed, and the line of 
the inferior margin is straight; in this position retain the fragments a 
few minutes, until the gum has well hardened. Meantime it will be 
practicable, generally, to introduce the fingers into the mouth, and to 
press the gutta percha laterally on each side toward the teeth, and 
thus to make its position more secure. When it is hardened, remove 
the splints, for the purpose of determining more precisely that they 
are properly shaped and fitted. 

It is scarcely necessary to say that in carrying the long wedge- 
shaped block into the mouth, the apex of the wedge is to be introduced 
first. 

The superiority of this splint is now at once perceived. If properly 
made, it is smooth upon its surface, and not, therefore, so liable to irri- 
tate the mouth as wood or cork, and it is so moulded to the teeth that 
it will never become displaced. It possesses this advantage, also, that 
in case more or less of the teeth are gone in either the upper or lower 
jaw, it fills up the vacancies, and renders the support uniform and 
steady. 

The " clasp," applied over the crowns and sides of the teeth, is not 
intended to act as an interdental splint ; but by its lateral pressure it 
is expected to hold the fragments in apposition upon nearly the same 
principle with the ligature. 

Mutter, of Philadelphia, and N. R. Smith, of Baltimore, employ for 
this purpose a plate of silver, folded snugly over the tops and sides of 
two or more teeth adjacent to the fracture. 

Nicole, of Nuremberg, employed for the same purpose a couple of 
steel plates fitted accurately along the anterior and posterior dental 
curvatures, secured in place by a steel clasp, the clasp being furnished 
with a thumb-screw, in order the more effectually to accomplish the 
lateral pressure. 

Malgaigne has extended the idea of Nicole, by substituting for the 
two steel plates a single plate composed of flexible and ductile iron, 
which is fitted accurately to all the irregularities of the posterior dental 
arch. From the two extremities of this plate, and from two other in- 
termediate points, four small steel shafts arise perpendicularly, cross 
the crowns of the teeth at right angles, and then fall down again per- 
pendicularly upon the anterior dental arcade. Each steel shaft being 
furnished with a thumb-screw, the iron plate can now be made to bear 
against the teeth so as to form a posterior dental splint. The teeth are 
also protected in front against the direct action of the thumb-screw by 
the interposition of a leaden plate. 

J. B. Gunning, dentist, of New York, has substituted for all these 
materials vulcanized india-rubber, which he employs both as a clasp 
and as an interdental splint; and, according to Dr. Covey, 1 the same 

1 Bean, Richmond Med. Journ., Feb. 1866. 



FRACTURES OF THE LOWER JAW. 127 

material has been used with excellent results by J. B. Bean, dentist, 
of Atlanta, Ga. The following is Dr. Bean's plan of procedure. 

An impression is taken in wax of the crowns of the teeth of the 
uninjured jaw, and of each fiagment separately of the broken jaw. 
When, in doing this, the ordinary "impression cup" used by dentists 
cannot be introduced, one composed of a thin metallic plate, which is 
covered with wax and stiffened by a rim of wire, may be substituted. 

" From these impressions are made casts of plaster of Paris, very 
carefully prepared, so as to produce a smooth, hard surface, and giving 
as perfect a representation of the teeth as possible. These plaster 
models are then adjusted, properly antagonized in their normal posi- 
tion and placed in the i maxillary articulator.' 

" The fragments of the model representing the broken jaw are held 
in their proper position by wax, being secured thus one to the other, 
and to the remaining plate of the articulator." . . . The model jaws 
are now opened from three to five lines, and a wax model of a splint is 
built up between the molars, covering also the inner and outer surfaces 
of the teeth. A connecting band of wax is laid from one side to the 
other behind the upper front teeth, leaving thus an opening in front 
for the reception of the food. This wax and plaster model, now com- 
posing one piece, is then removed 

from the articulator, and placed fig. 28. 

in a dentist's " flask," and a com- 
plete mould of the model is again 
formed from plaster laid on in sec- 
tions, in a manner which those ac- 
customed to make plaster moulds 
will readily understand. The 
plaster having fairly set, the flask 
and mould are opened, the wax 
carefully removed, and the spaces 

thus left in the mould at Once Maxillary Articulator. 

filled with the rubber rendered i, 1. upper and lower plates. 

. 2, 2. Adjustable rods. . 

soft by heat, lhe mould is again 3> 3 . Adjustable hinge. 

closed, replaced in the flask, and by 

heat the rubber is thoroughly vulcanized. The flask is again opened, 

the plaster removed, and an interdental splint of rubber remains, 

which is fitted accurately to all the surfaces of the teeth both above 

and below. 

The splint is now placed in the mouth, adjusted to the teeth, and the 
lower jaw secured in position by the apparatus represented in the ac- 
companying woodcut. 

Dr. Covey says, that during the late war Dr. Bean was placed in 
charge of a hospital at Macon, Georgia, devoted exclusively to the re- 
ception of this class of injuries, and that over forty cases were treated, 
and with eminent success. 

My own judgment of this apparatus is, that so far as the substitution 
of vulcanized rubber for gutta percha is concerned, it is wholly un- 
necessary in the great majority of simple fractures of the jaw. Gutta 
percha is applied with great facility, and with equal accuracy to all the 




128 



FRACTURES OF THE LOWER JAW 



Fig. 29. 




Bean's apparatus for broken jaw, applied. 



dental surfaces, and it speedily hardens sufficiently for all practical 
purposes. 

In gunshot fractures, however, and in certain other badly comminuted 
fractures, I can well understand how the surgeon may advantageously 

avail himself of vulcanized rubber, 
which, being somewhat harder, may 
be made to grasp the teeth attached 
to the several fragments more firmly ; 
and indeed may, in a few cases, allow 
of the teeth being made fast to the 
splint by screws. 

It will be observed that these are 
the cases which Dr. Bean has had 
chiefly under treatment. 

An examination of the cases re- 
ported by Dr. Covey will also show 
that the apparatus was never applied 
earlier than the tenth day, even when 
the patients were under the charge of 
Dr. Bean from the first, and that in 
most cases the application of the ap- 
paratus was delayed to a much later 
period. Indeed, it is apparent that 
there may be the same reasons for occasional delay in the application 
of vulcanized rubber as in the application of gutta percha, or any other 
mode of support and dressing. 

In reference to the head apparatus, or sling, as used by Dr. Bean, we 
have only a single remark to make. It is a modification of the appa- 
ratus employed for many years by myself — the modification consisting 
in the use of a horizontal piece of wood supporting a cup which is 
placed under the chin, the purpose of which is to prevent the lateral 
pressure usually made by the maxillary bands. The necessity of 
avoiding lateral pressure in certain cases, has long been recognized 
by myself and others; and it has been found to be especially im- 
portant in all comminuted and gunshot fractures. To the attain- 
ment of this purpose, I have employed usually a firm gutta percha 
splint under the chin, to the projecting lateral extremities of which the 
maxillary bands have been attached ; and I think it much better than 
Dr. Bean's piece of wood. In a great majority of cases, however, oc- 
curring in civil practice, that is to say, in most simple fractures, this 
submental splint is unnecessary, since the lateral pressure is harmless, 
especially when the interdental splints of gutta percha or of vulcanized 
rubber are employed. 

In short, while I am prepared to admit that Dr. Bean has by his 
appareil, and by the application of great mechanical skill, talent, and 
industry, treated successfully many cases which by other appliances and 
in other hands might have resulted most unfortunately, yet it is plain 
that his method will find its field of usefulness in civil practice limited 
to exceptional cases. 

Dr. J. S. Prout, of Brooklyn, New York, has suggested to me a very 



FftACTURES OF THE LOWER JAW. 129 

ingenious mode of employing the interdental splint and wire ligature 
conjointly, and which method, at ray request, he adopted recently in a 
case under my care at Bellevue Hospital. A plate of gutta percha was 
placed upon the top of the teeth across the line of fracture, and this 
was secured in position by silver wire, which had been made to grasp 
firmly the crowns of the adjacent teeth and was then brought over the 
horizontal gutta-percha plate. In this case it accomplished all that 
was desired. 

External splints, applied along the base or outside of the jaw, were 
first recommended by Pare, who used for this purpose leather; and 
they have been employed in some form, occasionally, by most surgeons. 
Generally they have been composed of flexible materials, such as wetted 
pasteboard, first recommended by Heister, felt, linen saturated with the 
whites of eggs, paste, dextrin, or starch; plaster of Paris has also been 
used; and they have been retained in place by either bandages or the 
sling. As before stated, I have myself used for this purpose gutta 
percha, but I shall speak of it as one form of the sling dressing. 

Undoubtedly useful, and even necessary in some cases, especially 
where there exists a great tendency to a vertical displacement, they will 
be found, also, in many cases, to render no essential service, and may 
properly enough be dispensed with. 

Whatever objections hold to the use of metallic clasps, must apply 
in some degree to the use of those forms of apparatus in which it is 
attempted to secure the fragments by means of a combination of these 
clasps with outside splints, and in which it is proposed to dispense with 
all bandages or slings, the mouth being permitted to open and close 
freely during the whole treatment. Motion of the jaw cannot be per- 
mitted in any case where the fracture is far back, since it is then im- 
possible to grasp the posterior fragment between the two parallel splints. 
Nothing but complete immobility of the jaw will now insure immo- 
bility to the fracture. Some of these forms of apparatus are liable to 
additional objections, which will be readily suggested by an explanation 
of their mode of construction. 

Chopart and Desault originated this idea as early as 1780, for frac- 
tures occurring upon both sides; in which cases they advised "band- 
ages composed of crotchets of iron or of steel, placed over the teeth, 
upon the alveolar margin, covered with cork or with plates of lead, and 
fastened by thumb-screws to a plate of sheet-iron, or to some other 
material under the jaw." 

The apparatus invented by Rutenick, a German surgeon, in 1799, 
and improved by Kluge, is thus described by Dr. Chester: "It con- 
sists, 1st, of small silver grooves, varying in size according as they are 
to be placed on the incisors or molars, and long enough to extend over 
the crowns of four teeth ; 2d, of a small piece of board, adapted to the 
lower surface of the jaw, and in shape resembling a horseshoe, having 
at its two horns, two holes on each side ; 3d, of steel hooks of various 
sizes, each having at one extremity an arch for the reception of the 
lower lip, and another smaller for securing it over the silver channels 
on the teeth, and at the other end a screw to pass through the horse- 
shoe splint, and to be secured to it by a nut and a horizontal branch at 



130 FRACTUKES OF THE LOWER JAW. 

its lower surface; 4th, of a cap or silk nightcap to remain on the head ; 
and 5th, of a compress corresponding in shape and size with the splint. 
The net or cap having been placed on the head, and the two straps 
fastened to it on each side, one immediately in front of the ear and the 
other about three inches farther back, which are to retain the splint in 
its position by passing through the two holes in each horn, a silver 
channel is placed on the four teeth nearest to the fracture ; on this the 
small arch of the hook is placed, and the screw end having been passed 
through a hole in the splint, is screwed firmly to it by the nut, after a 
compress has been placed between the splint and the integuments below 
the jaw. 

" If there is a double fracture, two channels and two hooks must of 
course be used." 1 

Bush invented a similar apparatus in 1822, 2 and Houzelot in 1826 ; 
since which the apparatus has been variously modified by Jousset, 
Lonsdale, Malgaigne, and perhaps others. 

Lonsdale says he has employed his instrument in numerous cases, 
and with complete success. 3 Rutenick succeeded with his apparatus 
in a case where the displacement persisted in spite of all other means. 4 
Jousset was also successful in two cases. 5 Wales, Asst. Surg. U. S. 
Navy, succeeded with an instrument of his own invention. 6 

But others have not been equally fortunate; or if they have succeeded 
in holding the fragments in apposition, and in securing a bony union, 
other serious accidents have followed. 

In the first case mentioned by Houzelot, the instrument was kept on 
thirteen days, after which an attack of epilepsy deranged everything, 
and the patient was transferred to Bicetre. The second patient com- 
plained immediately of an intense pain under the chin, and a profuse 
salivation followed. These symptoms were subdued by the sixth day, 
but, for some reason, the apparatus was finally removed on the tenth 
day. The fragments hereafter showed no tendency to derangement. 
Seven days after its removal, an abscess, which had formed under the 
chin, was opened. In the third case the apparatus was left in place 
thirty days, and an abscess formed also under the chin. Neucourt ap- 
plied it in a double fracture where the central fragment was much dis- 
placed. The apposition was well preserved, but he was obliged to 
remove it on the seventeenth day on account of a phlegmon which was 
forming under the chin. The patient to whom Bush applied his ap- 
paratus, would wear it but a few days. Malgaigne had the same ex- 
perience with Bush's apparatus. 

In addition to the pain and inflammation, followed by submaxillary 
abscesses, which have been such frequent results of its use, Malgaigne 
has noticed that it is exceedingly inclined to slide forwards and become 
displaced. 

1 London Med.-Chir. Rev., vol. xx, p. 471, from Monthly Archives of the Medi- 
cal Sciences, 1834. 

2 Malgaigne, op. cit., p. 395. 

3 Lonsdale, Practical Treatise on Fractures ; London, 1838, p. 234. 

4 Malgaigne, op. cit., p. 396. 5 Ibid., p. 396. 
6 Wales, Am. Journ. Med. Sci., Oct. 1860. 



FRACTURES OF THE LOWER JAW. 



131 



Fig. 30. 



In short, notwithstanding the unqualified testimony of Lonsdale in 
favor of this method of treatment, especially in fractures at the sym- 
physis, and in fractures through any portion of the shaft anterior to 
the masseter muscle, it is, in my judgment, sufficiently plain that it is 
applicable to only a very limited number of cases ; but if I were to 
recommend any form of apparatus constructed with a view of per- 
mitting mobility of the jaws during the process of union, it would be 
that invented by Norman Kingsley, dentist, of this city, and which I 
have seen used with excellent results at Bellevue Hospital. 

Impressions in plaster are first taken of both upper and lower jaws. 
Models made from these impressions will represent the lower jaw 
broken and the fragments dis- 
placed. The model of the lower 
jaw is then separated at the point 
representing the fracture, and the 
fragments adjusted to the model of 
the upper jaw. In most cases the 
position w T hich these fragments 
assume when thus placed, deter- 
mines accurately the original form 
and position of the lower jaw. 
Upon the plaster model of the 
lower jaw, obtained and rectified 
in this way, a splint or clasp of 
vulcanite rubber is then made, embracing the arms, which are made 
of steel wire, one-sixteenth of an inch in diameter. The arms must 
curve upwards a little as they emerge from the mouth, to avoid pres- 
sure upon the lips, and then curve backwards, terminating near the 
angles of the jaw. 

When the apparatus is applied, the teeth must be pushed into the 




Plaster model of jaws. 



Fig. 31. 




Kingsley's apparatus reversed. 



sockets of the splint with some force. The dressing is now completed 
by a sling made of strong muslin, extending beneath the chin from one 
arm to the other. 

George L. Fitch, dentist, California, believes that "dental gutta 
percha" may be made to answer the same purpose as vulcanite rubber, 



132 



FRACTURES OF THE LOWER JAW. 



in the construction of this and other similar splints. 1 In this opinion, 
however, Dr. Kingsley does not concur. 



Fig. 32. 




Same, applied to model. 



Fig. 33. 



The treatment of fractures of the inferior maxilla by a single-headed 
bandage or roller, numbers among its distinguished advocates the 

names of Gibson and Barton ; indeed, I 
think the practice is at the present time 
peculiar to a few American surgeons. 
Gibson gives the following directions 
for applying his roller : " A cotton or 
linen compress, of moderate thickness, 
reaching from the angle of the jaw nearly 
to the chin, is placed beneath, and held 
by an assistant, while the surgeon takes 
a roller, four or five yards long, an inch 
and a half wide, and passes it by several 
successive turns under the jaw, up along 
the sides of the face, and over the head ; 
now changing the course of the bandage, 
he causes it to pass off at a right angle 
from the perpendicular cast, and to en- 
circle the temple, occiput, and forehead, 
horizontally, by several turns ; finally, to render the whole more secure, 
several additional horizontal turns, are made around the back of the 
neck, under the ear, along the base of the jaw, under the point of the 
chin. To prevent the roller from slipping or changing its position, a 
short piece may be secured by a pin to the horizontal turn that encir- 
cles the forehead, and passed backwards along the centre of the head 




Gibson's bandage for a fractured jaw. 



1 Fitch, New York Med. Gazette, 1869. 



FRACTURES OF THE LOWER JAW. 



133 



Fig. 34. 



as far as the neck, where it must be tacked to the lower horizontal 
turn — taking care to fix one or more pins at every point at which the 
roller has crossed." 

Barton employs, also, a compress, and a roller five yards long; the 
application of which is thus described by Sargent: Place the initial 
extremity of the roller upon the occiput, just 
below its protuberance, and conduct the 
cylinder obliquely over the centre of the left 
parietal bone to the top of the head ; thence 
descend across the right temple and the zy- 
gomatic arch, and pass beneath the chin to 
the left side of the face ; mount over the left 
zygoma and temple to the summit of the 
cranium, and regain the starting-point at the 
occiput by traversing obliquely the right 
parietal bone; next, wind around the base of 
the lower jaw on the left side to the chin, 
and thence return to the occiput along the 
right side of the maxilla ; repeat the same 
course, step by step, until the roller is spent, 
and then confine its terminal end. 

These bandages possess the advantages of being easily obtained, of 
simplicity and facility of application, and, we may add, if considered 
in relation to the majority of simple fractures, of tolerable adaptation 
to the euds proposed. The only objections to their use which I have 
ever noticed, are occasional disarrangements, and the tendency, as in 
all other continuous rollers, to draw the fragments to one side or the 




Barton's bandage for a 
fractured jaw. 



other, according as the successive turns 



(i to the right 



Fig. 35. 



of the bandage are car 
or left. There is one other objection, 
having reference to the occasional in- 
adequacy of this dressing to prevent 
an overlapping of the fragments ; to 
which objection also the sling, as 
usually constructed, is equally obnox- 
ious, and of which I shall speak pres- 
ently. 

Finally, it is to the sling, in some 
of its various forms, with or without 
the interdental splint, that surgeons 
have generally given the preference. 
The sling is known, also, by the name 
of the four-headed or the four-tailed 
roller or bandage. 

B. Bell, Boyer, Skey, S. Cooper, 
B. Cooper, Syme, Fergusson, Mayor, 
Lizars, and Chelius employ the sling, 
usually; and the favorite mode is to 

use for this purpose a piece of muslin cloth about one yard long and 
four inches wide, torn down from its two extremities to within about 




Four-tailed, bandage or sling for the 
lower jaw. 



134 FRACTURES OF THE LOWER JAW. 

three or four inches of the centre. Others have used leather, gutta 
percha, adhesive straps, gum-elastic, etc. 

Where the muslin is used, it is quite customary to lay against the 
skin a piece of pasteboard, wetted, and moulded to the chin, or simply 
a soft compress ; and some choose to open the centre of the bandage 
sufficiently to receive the chin. The middle of this bandage being 
laid upon the chin, the two ends corresponding to the upper margin 
of the roller are now carried across the front of the chin, behind the 
nape of the neck, and made fast ; while the two lower heads are brought 
directly upwards from under the sides of the chin, along the sides of the 
face, in front of the ears, and made fast upon the top of the head. The 
dressing is completed by a short counter-band extending across the 
top of the head from one bandage to the other ; or the several bands 
may be made fast to a nightcap, in which case the counter-band will 
be unnecessary. 

It only remains for me to describe my own method of dressing these 
fractures with the sling. 

Having frequently noticed the tendency of the sling, as ordinarily 
constructed, and of Gibson's roller, to carry the anterior fragment 
backwards, especially in double fracture where the body of the bone 
is broken upon both sides, I devised, some years since, an apparatus 
intended to obviate this objection, and which I have used now many 
times with entire satisfaction. 

It is composed of a firm leather strap, called maxillary, which, pass- 
ing perpendicularly upwards from under the chin, is made to buckle 
upon the top of the head, at a point near the situation of the anterior 
fontanelle. This strap is supported by two counter-straps, made of 
strong linen webbing, called, respectively, the occipito-frontal and the 
vertical. The occipito-frontal is looped upon the maxillary at a point 
a little above the ears, and may be elevated or depressed at pleasure. 
The occipital portion of the strap is then carried backwards and buckled 
under the occiput, while the frontal portion is buckled across the fore- 
head. The vertical strap unites the occipital to the maxillary across the 
top of the head, and prevents the upper part of the latter from becom- 
ing displaced forwards. At each point where a buckle is used, a pad 
must be placed between the strap and the head. 

The maxillary strap is narrow under the chin, to avoid pressure upon 
the front of the neck, but immediately becomes wider, so as to cover 
the sides of the inferior maxilla and face, after which it gradually di- 
minishes, to accommodate the buckle upon the top of the head. The 
anterior margin of this band, at the point corresponding to the sym- 
physis menti, and for about two inches on each side, is supplied with 
thread-holes, for the purpose of attaching a piece of linen, which, when 
the apparatus is in place, shall cross in front of the chin, and prevent the 
maxillary strap from sliding backwards against the front of the neck. 

The advantage of this dressing over any which I have yet seen, con- 
sists in its capability to lift the anterior fragment almost vertically, 
while at the same time it is in no danger of falling forwards and 
downwards upon the forehead. If, as in the case of most other dress- 
ings, the occipital stay had its attachment opposite to the chin, its 



FRACTURES OF THE LOWER JAW. 



135 




effect would be to draw the central fragment backwards. By using a 
firm piece of leather, as a maxillary band, and attaching the occipital 
stay above the ears, this difficulty is completely obviated. 

Having removed such teeth as are much loosened at the point of 
fracture, and replaced those which are loosened at other points, unless 
it be far back in the mouth, and ad- 
justed the fragments accurately, the 
lower jaw is to be closed completely 
upon the upper, and the apparatus 
snugly applied. It is not necessary 
in most cases to buckle the straps 
with great firmness, since experience 
lias shown that a sufficient degree of 
immobility is usually obtained when 
the apparatus is only moderatelv 
tight. 

If the integuments are bruised and 
tender, a compress made of two or 
more thicknesses of patent lint should 
be placed underneath the chin, be- 
tween it and the leather. 

If the inability to introduce 
nourishment between the teeth when 
the mouth is closed, or the irregu- 
larity of the dental arcade renders 
the use of interdental splints neces- 
sary, gutta percha, as I have already explained, ought, in general, to 
be preferred to any other material. 

The patient must be forbidden to talk or laugh, and when he lies 
down, his head should rest upon its back, for whatever mode of dress- 
ing is employed, and however carefully it is applied, it will be found 
that a slight motion and displacement will occur whenever the weight 
of the head rests upon the side of the face. 

Occasionally, indeed, as often as every two or three days, the appa- 
ratus may be loosened or removed, only taking care generally not to 
disturb the interdental splints, when they are used, and to support the 
jaw with the hand, during its removal ; and, at the same time, the face 
may be sponged off with warm water and castile soap. It should not 
be left off entirely, however, in less than three or four weeks, even 
where the fracture is most simple, nor ought the patient be allowed to 
eat meat in less than four or five weeks. 

To cleanse the mouth and prevent offensive accumulations, it should 
be washed several times a day with a solution of tincture of myrrh, 
prepared by adding one drachm to about four ounces of water. 

The same apparatus, and without any essential modification, is ap- 
plicable to fractures of the symphysis and of the angle of the inferior 
maxilla, as well as to fractures of the body of the bone. 

Instead of the leather, I have in a few instances, especially of com- 
pound fractures where it became necessary to allow the pus to discharge 
externally, used a sling or a splint composed of gutta percha, suspended 



The author's apparatus. 



136 FRACTURES OF THE LOWER JAW. 

by bands carried over the top of the head. The piece from which this 
splint is made should be three or four lines in thickness, covered with 
cloth, and padded under the chin. It will be found convenient to 
cover it with cloth before immersing it in the hot water. The water 
should be nearly at a boiling temperature, so that the splint may be- 
come perfectly pliable; and it should be laid upon the face and allowed 
to mould itself while the patient lies upon his back. 

Having thus fitted it accurately to the face, it may be removed and 
openings made at points corresponding with the wounds upon the skin, 
before it is reapplied. 

As has been already explained, the gutta percha, if sufficiently thick, 
and if the lateral wings are allowed to project a little on either side, 
will serve effectually to protect the sides of the face against pressure 
from the bandage ; and being more easily moulded to the base and 
front of the chin than any other material which has yet been employed, 
must have the preference. The necessity for its use, however, is only 
occasional. 

In fractures of either condyle, unaccompanied with displacement, 
the simple leather or muslin sling will sometimes accomplish a perfect 
and speedy cure, as the two cases reported by Desault will sufficiently 
demonstrate. But if the fragments have become separated, the replace- 
ment is difficult, and the retention uncertain. 

Ribes was the first to suggest and to practice a very ingenious 
method of reduction in these cases. Having seen two examples which 
had resulted in deformity under the usual treatment, which consisted 
in simply pressing forwards the angle of the jaw, it occurred to him 
that while the upper or condyloidean fragment was not acted upon at 
the same moment by pressure from the opposite direction, a reduction 
must be impossible. The case of a cannoneer whose jaw was broken 
through the neck of the condyle on the right side, and through its 
body on the left, afforded him an opportunity to determine the prac- 
ticability of a method of which he had as vet only conceived the idea. 
Malgaigne thus describes his procedure : " AVith the left hand seize the 
anterior portion of the jaw, for the purpose of drawing it horizontally 
forwards, while you carry the index finger of the right hand to the 
lateral and superior part of the pharynx. You will meet at first the 
projection formed by the styloid process, but, moving your finger for- 
wards, you will find soon the posterior border of the ramus of the jaw; 
and following this border from below upwards, you will arrive at the 
inner side of the condyle, which you will push outwards in such a 
manner as to engage it upon the other fragment. This manoeuvre 
cannot be made without causing nausea, as the finger always does when 
carried into the posterior part of the pharynx ; but this is a slight in- 
convenience. The reduction obtained, bear the jaw upwards and back- 
wards in order to press and fix the condyle between it and the glenoid 
cavity, then fasten it in place with a sling." The fragments were thus 
easily brought into apposition in the case reported by Kibes, and the 
patient was cured without any deformity. 

In addition to these means, the angle of the jaw ought to be pressed 
permanently forwards by means of a compress placed between it and 



FRACTURES OF THE HYOID BONE. 137 

the mastoid process, and held in place by a suitable bandage ; or we 
may adopt the method which proved so successful with Fountain, 
namely, wire the front teeth of the lower jaw to the front teeth of the 
upper in such a manner as to draw the chin forwards, and thus main- 
tain apposition. 

If the coronoid process be alone broken, it is sufficient to close the 
mouth with any form of sling or bandage which may be most conve- 
nient. 



CHAPTER XIII. 

ERACTUKES OF THE HYOID BONE. 

M. Orfila has reported the case of a man, aged sixty-two years, 
who had been hanged, and whose os hyoides was broken through its 
body on its right side. 1 M. Cazauvieilh has also seen a fracture of 
this bone in two persons who had been hanged : in one of which tb^ 
fracture was probably in the body of the bone, and in the other througu 
one of its cornua. 2 

Lalesque published in the Journal Hebdomadaire for March, 1833, a 
case which occurred in a marine, sixty-seven years old, "who, in a 
quarrel, had his throat violently clenched by the hand of a vigorous 
adversary. At the moment there was very acute pain, and the sensa- 
tion of a solid body breaking. The pain was aggravated by every 
effort to speak, to swallow, or to move the tongue, and when this organ 
was pushed backwards, deglutition was impossible. The patient could 
not articulate distinctly ; and he was unable to open his mouth without 
exciting a great deal of pain. He placed his hand upon the anterior 
and superior part of his neck to point out the seat of the injury. This 
part was slightly swollen, and presented on each side small ecchymoses; 
one above, more decided, immediately under the left angle of the lower 
jaw. The large cornua of the os hyoides was very distinctly to the 
right side," and it could be felt on the left deeply seated by pressing 
with the fingers ; in following it in front toward the body of the bone, 
a very sensible inequality near the point of junction of these two parts 
could be perceived. By putting the finger within the mouth, the same 
projections and cavities inverted could be felt, and even the points of 
the bone which had pierced the mucous membrane, etc., were evident. 
Having bled the patient, and placed a plug between his teeth to keep 
the mouth open, the broken branch was brought by the finger back to 
the surface of the body of the bone, and easily reduced. The position 
of the head inclined a little back; rest, absolute silence, diet, and some 
saturnine fomentations, composed the after-treatment. To avoid a new 
dislocation by the efforts of swallowing, the oesophagus-tube of Desault 

1 Traite de Med. legale, troisieme ed., torn, ii, p. 423. 

2 Cazauvieilh, du Suicide, etc., p. 221. 

10 



138 FRACTURES OF THE HYOID BONE. 

was introduced, to conduct the drinks and liquid aliments into the 
stomach; this sound was allowed to remain until the twenty-fifth day; 
at this time the patient could swallow without pain, and began to take 
a little more solid nourishment, and at the end of two months the cure 
was complete. By placing a finger within his mouth, a slight nodosity 
could be felt in the place where, in the recent fracture, the splintered 
points were perceptible. 1 

Dieffenbach has also recorded a fracture of the great right horn, pro- 
duced in the same manner, by grasping the throat between the thumb 
and fingers, which occurred in a girl only nineteen years old. Very 
slight pressure upon the side of the bone was sufficient to move the 
fragment inwards, and. to produce a crepitus ; but it immediately re- 
sumed its place w T hen the pressure was removed. There being, there- 
fore, no displacement, the cure was effected in a short time without 
resort to any remedies except tisans and antiphlogistics. She was not 
even forbidden to speak. 2 

Auberge saw a similar case, in a person fifty-five years old, occasioned 
by grasping the throat. The fracture was in the great horn of the right 
side, and the displacement was so complete that crepitus could not be 
felt, and the mucous membrane of the pharynx was penetrated by the 
broken bone. 3 

The following example is reported by Dr. "Wood, of Cincinnati, 
Ohio, as having come under his observation in the year 1855 : 

" Through the kindness of our friend Dr. P. G. Fore of this city, 
we were invited to examine a case of fracture of the os hyoides, that 
had occurred about one week before we saw it, in one of his patients. 
The patient was a female, about thirty years of age, who had fallen 
down the cellar steps, striking the prominent parts of the larynx and 
hyoid bone against a projecting brick, severely injuring the larynx as 
well as fracturing the bone. 

" The fracture was on the left side, and near the junction of the 
great horn with the body of the bone. Crepitus was distinctly felt on 
pressing the bone between the thumb and finger ; or w T hen the patient 
would swallow ; though, at this time, the severe symptoms that fol- 
lowed the accident, and continued for several days, had somewhat sub- 
sided. 

" Immediately after the accident there was profuse bleeding from 
the fauces, and she experienced great difficulty and pain in the act of 
swallowing, and the power of speech was almost entirely lost. On at- 
tempting to depress or protrude the tongue, she felt distressing symp- 
toms of suffocation. Considerable inflammation and swelling of the 
throat and larynx ensued, and continued in some degree up to the time 
of our visit. 

"To-day (about four weeks since the accident) Dr. F. informs us 
that the patient has so far recovered as to be able to converse, though 

1 Amer. Journ. Med. Sci., vol. xiii, p. 250. 

2 Medic. Vereinszeitung fur Preussen, 1833, No. 3; Gazette Med., 1834, p. 187. 

3 Revue Med., July, 1835. 



FRACTURES OF THE HYOID BONE. 139 

the voice is somewhat impaired. She is yet unable to swallow solid 
food, and is wholly sustained by fluids." 1 

Marcinkovsky saw a woman in whom both the lower jaw and the 
left horn of the os hyoides were broken by a fall from her carriage 
against a wall. She died in about twenty-four hours, from suffoca- 
tion. 2 

Dr. Grander reports the following : 

"A laborer, set. 63, fell from a wagon on his face, and discharged a 
large quantity of blood by the mouth. He found he could not swal- 
low, and when seen twelve hours afterward, complained of severe pain 
in the neck and nape, with inability to turn his head, though no injury 
of the vertebrae could be detected. His voice was hoarse and difficult. 
On attempting to drink, the fluid was rejected with violent coughing, 
the patient declaring he felt it as if entering the air-passages. An ex- 
amination of the fauces led to no explanation of this condition. The 
epiglottis did not, however, appear to completely close the larynx, or 
to be in its exact position. The tongue was movable in all directions, 
and pressing it down with a spatula caused no inconvenience. The 
hyoid seemed to possess its continuity. No crepitation or abnormal 
movability could be perceived, and no pain at the root of the tongue 
occurred on attempting to swallow. After repeated examinations, the 
case was concluded to be one in which the functions of the nervus 
vagus had undergone great disturbance, or the muscles of the larynx 
had become torn or paralyzed. Medicine and food were administered 
by means of an elastic tube. The patient had a good appetite and 
slept well ; the pain of the neck was lost, and its motion recovered ; a 
hectic cough, from which he had long suffered, alone remaining. After 
continuing, however, to go on thus well for six days, the cough in- 
creased; the appetite failed; strength was lost; the voice was scarcely 
audible; and in five more days the patient died exhausted. At the 
autopsy a fracture of the os hyoides was found. One of the large cor- 
nua was broken, and had become firmly imbedded between the epi- 
glottis and rima glottidis, inducing the raised position of the epiglottis, 
loss of voice, and difficulty in swallowing. The fracture was probably 
produced by muscular action, a cause first assigned in a case occurring 
to Ollivier d' Angers." 3 

I think it more probable that this fracture was the result of a direct 
blow, than of muscular action. In the case referred to, however, as 
having been reported by Ollivier, there can be no doubt that the frac- 
ture was due to muscular action alone. 

A woman, fifty-six years old, made a misstep and fell backwards, 
and at the same moment that her head was thrown violently back, she 
felt distinctly a sensation as if a solid body had broken, in the upper 
part of her neck and upon its left side. An examination showed- that 
she had fractured the great left horn of the os hyoides. Inflammation 

1 Western Lancet; also N. Y. Journ. Med., vol. xv, p. 152. 

2 Medic. Vereinszeitung fur Preussen, 1833, ISTo. 15; Gazette Medicale, 1833, p. 
354. 

3 Schmidt's Jahrbuch., vol. lxviii; also Amer. Journ. Med. Sci., vol. xlix, p. 
253, Jan. 1852. 



140 FRACTURES OF THE HYOID BONE. 

and suppuration followed, and finally, after about three months, the 
posterior fragment made its way out in a condition of necrosis, and the 
fistula promptly healed, but there remained for many years a sense of 
uneasiness about these parts when she swallowed, sometimes amounting 
to pain. 1 

Etiology. — Of the ten cases which I have found upon record, three 
were produced by hanging ; three by grasping the throat between the 
thumb and fingers ; three by direct blows, or by falls upon the front of 
the neck ; and one by muscular action alone. 

The observation of Mr. South, that fracture of the bone " is almost 
invariably found" 2 in persons executed by hanging, is probably incor- 
rect, since although a large proportion of these subjects are submitted 
to dissection both in this and other countries, yet I know of but these 
three examples which have been published. 

Pathology, Symptomatology, and Diagnosis. — The body of the bone 
seems to have been broken in all of those cases which resulted from 
hanging ■ while in all of the other examples the fracture has occurred 
in one of the great horns, or at the junction of the horns with the body. 
Generally the displacement inwards of one of the fragments has been so 
complete that crepitus could not be detected. It was present, however, 
in the examples mentioned by Dieffenbach and Wood. In two in- 
stances the mucous membrane has been penetrated, and in one the 
fragment was projected between the epiglottis and rima glottidis. 

The accident has been characterized by a sudden sensation as if a 
bone had broken ; in a few instances, by profuse bleeding from the 
fauces ; by difficulty in opening the mouth ; by impossibility of deglu- 
tition, and by loss of voice in others; with great pain in moving the 
tongue, the pain being especially at its root ; in one instance the tongue 
was perceptibly drawn to one side. There is usually more or less 
swelling and soreness about the neck, with ecchymosis; and at a later 
period, cough, expectoration, hoarseness, etc. The circumstances which, 
however, indicate certainly the nature of the accident, are preternatural 
mobility of the fragments, with or without crepitus, and the angular 
inward projection, which may in most cases be distinctly felt in a care- 
ful examination of the pharynx. 

In the case related by Griiner, the only symptoms were a loss of 
voice, difficulty of deglutition, and a sensation, when the attempt was 
made to swallow, as if the fluids passed into the windpipe ; with also 
an imperfect closure of the epiglottis upon the rima glottidis. No pre- 
ternatural mobility or irregularity in the fragments could be detected, 
nor was there crepitus, and it was concluded that the bone was not 
broken, yet the autopsy showed that the fragment was imbedded deeply 
between the epiglottis and the rima glottidis. 

Prognosis. — It is only in view of its complications that this accident 
can be regarded as serious; where the severity of the injury has been 
such as to fracture the lower jaw at the same time, as in the case related 
by Marcinkovsky, or such as to bury the fragment deep in the tissues 

1 Malgaigne, op. cit., p. 405. 

2 Note to Chelius's Surgery, Amer. ed., vol. i, p. 581. 



THYROID CARTILAGE. 141 

about the riina glottidis, as in the case mentioned by Griiner, a favor- 
able termination could scarcely have been expected ; and these are the 
only cases yet published in which the death was in any way connected 
with the fracture. One-half of the whole number have died, but of 
these, three have died by hanging, and the remaining two from the 
causes named. Of the three in which the accident resulted from a 
direct blow, only the patient of Dr. Fore, of Cincinnati, has survived ; 
while of the three whose fractures resulted from lateral pressure upon 
the cornua all recovered ; so, also, did the patient in whom the fracture 
was produced by muscular action. 

Treatment. — No doubt when the fragments are displaced an attempt 
ought to be made to replace them by introducing one finger into the 
mouth, while with the opposite hand the fragments are supported from 
without. Lalesque found this a matter of some difficulty, but Auberge 
experienced no difficulty at all. I suspect, however, that the amount 
of difficulty will very much depend upon the degree of displacement, 
and the consequent lacerations of the soft tissues about the boue. But 
however this may be, it must be altogether another thing to be able to 
keep in exact apposition the broken ends of a bone whose diameter is 
so inconsiderable, and upon which it is quite impossible to apply any 
apparatus or dressings to retain the fragments in place. Lalesque 
threw the head of his patient slightly back, with the view of making 
" permanent extension ~ upon the fragments through the action of the 
muscles and ligaments attached to the bone, and he recommends this 
position as that which is best calculated to preserve the coaptation. 
Malgaigne, on the contrary, without having himself seen any example 
of this fracture, believes that the position of flexion of the neck, with 
entire relaxation of the muscles, would be most suitable. 

In all cases it will be proper to enjoin silence, and to adopt suitable 
measures to combat inflammation; such as general or topical bleeding, 
fomentations, moistening the mouth with cool water, or permitting 
small pieces of ice to rest in the mouth until dissolved, without in 
general allowing the fluid to be swallowed ; but in some examples, no 
doubt, the patient may be permitted to swallow. 



CHAPTEE XIV. 

FRACTURE OF THE CARTILAGES OF THE LARYNX. 

§ 1. Thyroid Cartilage. 

The examples of fracture of the larynx which may be found upon 
record are also very few. M. Ladoz examined the larynx of a man who 
had been assassinated, and upon whose neck he found a handkerchief 
bound so tightly as to leave, after its removal, a deep furrow ; but the 
neck showed also distinct marks produced by the fingers and thumb. 



142 FRACTURE OF THE CARTILAGES OF THE LARYNX. 

There was a fracture of the thyroid cartilage which extended obliquely 
downwards and outwards through its right wing. The whole of the 
larynx was very much ossified, although the subject was only thirty- 
seven years old. 1 

In 1823, M. Ollivier communicated to the Academy of Medicine a 
case in which, this cartilage being broken, the patient died of suffoca- 
tion. 2 

M. Marjolin says: "Two women at the hospital being engaged in a 
quarrel, one of them seized her antagonist by the throat, and griped 
her so strongly that she broke the thyroid cartilage from its upper to 
its lower margin. You will imagine that it was not very difficult to 
determine the existence of a fracture, and that no retentive apparatus 
was demanded. Silence, regimen, a small bleeding, and the cure was 
accomplished." 3 

Habicot operated successfully, in 1620, by introducing a leaden tube 
into the trachea in a case in which the thyroid was " damaged." Gibb, 
Norris, Nelaton, and Kenderline have each reported examples of frac- 
ture of this cartilage alone. 4 

I 2. Thyroid and Cricoid Cartilages. 

Plenck saw a fracture of both the thyroid and cricoid cartilages 
produced by falling upon the rim of a pail. 5 Morgagni also says that 
he had seen fractures of the larynx ; and Remer mentions a fracture of 
the larynx found in a person who had been hanged ; 6 but in neither 
case is it said in which cartilage the fracture occurred, or whether it 
had not occurred in both. 

Dr. O'Brian, of Edinburgh, reports in vol. xviii of the Edinburgh 
Med. and. Surg. Journ., a case of fracture of both cartilages, involving 
the trachea also, in a woman who had received a kick under the jaw, 
and who died on the following day. Hunt has collected other cases, 
some of which involved the arytenoid cartilages, the hyoid bone, the 
trachea, etc. 

I am able to furnish, from my own observation, another example of 
fracture of both the thyroid and cricoid cartilages : 

John Calkins, of Collins, Erie Co., N. Y., set. 41, is supposed to have 
been kicked by. a young horse on the 10th of November, 1856. He was 
alone in the stables when the accident occurred, and, being stunned by 
the blow, he could not himself give any account of the manner in which 
the injury was received. When found, he was sitting upright, but 
unable to articulate except in a whisper. Drs. Barber and Davis, of 
Colden, saw him about two hours after. His countenance was anxious ; 
his pulse feeble ; extremities cold ; and he was breathing with great 

1 Gazette Medicale, 1838, p. 698. 

2 Archives Generates de Medecine, tome ii, p. 307. 

3 Marjolin, Cours de Patholog. Chir., p. 396. 

4 Hunt, Frac. of Lar3'nx, etc. Am. Journ. Med. Sci., April, 1866. 
6 Malgaigne, op. cit., p. 409. 

6 Morgagni, de Sedibus, etc , Epist. 19, num. 13, 14, et 16 ; Kemer, Annales 
d'Hygiene, tome iv, p. 171 ; from Malgaigne. 



THYROID AND CRICOID CARTILAGES. 143 

difficulty. A small quantity of blood was issuing from his fauces. 
His upper lip was cut, and a few of his teeth dislocated; the wound 
appearing as if inflicted by one of the corks of the horse's shoes. 
There was no other wound; but over the left wing of the thyroid car- 
tilage there was a slight discoloration, pressure upon which produced 
intense pain and suffocation, and disclosed the fact that the thyroid 
prominence was depressed very much and broken. Cold lotions Avere 
directed to be applied, and as the thirst was excessive, but deglutition 
impossible, he was permitted to hold pieces of ice in his mouth. This 
plan, with but slight modifications, such as the substitution of warm 
fomentations to the neck for the cold lotions, was continued until the 
following evening, when, at the request of the attending physician, Dr. 
Barber, I was called to see him. The symptoms remained nearly the 
same as at first. He was unable to speak audibly, or perform the act 
of deglutition ; his breathing was difficult, and at times threatened 
suffocation. The lateness of the hour, with other circumstances, de- 
termined me to defer surgical interference until morning. At day- 
break of the 12th I made the operation of laryngotomy, and introduced 
a large double canula into the crico-thyroidean space. This operation 
was rendered difficult by the great amount of swelling about the neck, 
due both to emphysema, and bloody with serous infiltrations. The 
breathing immediately became easy, and gradually the appearance of 
asphyxia disappeared from his face; but after about six or seven hours 
he began perceptibly to fail in strength, and died at 3 o'clock p.m. of 
the following day, apparently from exhaustion rather than from suffo- 
cation ; having survived the accident about seventy -two hours, and the 
operation about thirty-four hours. 

The autopsy disclosed a comminuted fracture of the thyroid cartilage, 
with a simple fracture of the cricoid. The thyroid was broken almost 
perpendicularly through the centre ; the line of fracture being irregu- 
lar, and inclining slightly to the left side. The left inferior horn was 
broken off about three lines from its articulation with the cricoid car- 
tilage. The right ala was broken also in a line nearly vertical, but 
irregular, at a point about six lines from its posterior margin. The 
pomum Adami was depressed to the level of the cricoid cartilage, and 
the left ala, being completely detached, was thrown inwards and up- 
wards several lines. Underneath the perichondrium, especially upon 
the inner side, there was pretty extensive bloody infiltration. Ossifi- 
cation of the cartilages had commenced at several points, but it had 
made but little progress. The central fracture of the thyroid was 
through cartilage alone. The fracture of the right ala was through car- 
tilage until it reached a bony belt comprising the two inferior lines of its 
course. The left lower horn was ossified, and the fracture was through 
this bony structure. The fracture through the cricoid cartilage com- 
menced close upon the margin of a bony plate, but in its whole course 
it traversed only cartilage. It was on the left side. There was also 
an incomplete fracture on the right ala of the thyroid cartilage, com- 
mencing in the line of the principal fracture and extending obliquely 
downwards about three lines, until it was arrested by the bony plate 
which constituted the lower margin of this wing. 



144 FRACTURE OF THE CARTILAGES OF THE LARYNX. 

A ragged, lacerated wound in the back of the larynx, above the 
cricoid cartilages, communicated directly with the oesophagus. 

I 3. Cricoid Cartilage. 

Both Valsalva and Cazauvieilh have each met with a single example 
of this fracture, without fracture of the thyroid cartilage; and Weiss 
has found the cricoid cartilage broken into numerous fragments, and at 
the same time separated from the trachea. 1 

General Etiology of Fractures of the Laryngeal Carti- 
lages. — As a predisposing cause, advanced age, with its usual con- 
comitant, partial or complete ossification of the cartilages, has been 
thought to occupy a prominent place. In the case reported by Plenck, 
the cartilages were already very much ossified, although the subject was 
only thirty-seven years old. Morgagni observed that in his experience 
it had occurred always in advanced life. In my own case, however, 
the cartilages were only slightly ossified, the patient being forty-one 
years old ; nor did the lines of the several fractures indicate a prefer- 
ence for the bony plates ; but it seems to me that they rather avoided 
them, and in the case of the incomplete fracture the bone appeared to 
have arrested the fracture. In fact, a few experiments have satisfied 
me that the adult laryngeal cartilages are quite as brittle as bone, and 
consequently, that ossification in no way increases their liability to 
fracture. 

Hunt ascertained the age in fifteen cases, and but one of the whole 
number was over 45 years ; five occurred in children, one of whom was 
only four years old. 

The immediate causes have been direct blows, as falling upon the 
edge of a pail, a kick from a horse, or pressure, as in hanging, or in 
grasping the larynx strongly between the thumb and fingers. 

General Symptomatology, Etc. — The signs of this accident are 
such as may attend any severe injury of this organ, whether accom- 
panied with a fracture or not, such as pain, swelling, difficult degluti- 
tion, embarrassed respiration, loss of voice, cough, and perhaps bloody 
expectoration, with emphysema, etc. 

But none of these can be regarded as diagnostic ; although, when 
taken in connection with the history of the accident, especially if a very 
severe and direct blow has been received, or more certainly still when 
symptoms so grave and complicated have followed an attempt at stran- 
gulation by grasping the throat, they may be regarded as probable or 
presumptive evidences. 

A positive diagnosis must depend upon the presence of a sensible 
displacement, or motion of the fragments, with crepitus. 

In the case related by Plenck, death followed almost immediately, 
with convulsions, and without any outcry ; indicating, probably, some 
severe lesion of the spinal marrow ; while in M. Oliivier's patient 
suffocation ensued, at first intermittent, and finally permanent. 

1 Malgaigne, op. cit., p. 408. 



CRICOID CAETILAGE. 145 

In my own case, suffocation was throughout a prominent symptom, 
with only such slight intervals of amelioration as might have been 
occasioned by the extrication of the blood or mucus from the larynx. 

General Prognosis. — The prognosis ought to depend rather upon 
the complications and upon the gravity of the symptoms, than upon 
the simple decision of the question of fracture. A fracture produced 
by grasping the wings of the thyroid cartilage, and without any great 
contusion or laceration of the soft parts, might reasonably be expected 
to terminate favorably under judicious management; but when, on the 
contrary, the fracture is the result of great violence inflicted directly 
upon the front of the cartilages, producing severe contusion and lace- 
ration, and is followed by great swelling, emphysema, very difficult 
respiration, complete aphonia, impossibility of deglutition, etc., the 
prognosis cannot but be unfavorable. 

» 

General Treatment. — In examples of simple, uncomplicated 
fracture, " silence, regimen, and a small bleeding" may suffice; but in 
other cases it may become necessary to introduce a tube into the 
stomach, to supply the patient with food and drink, since deglutition 
may be impossible. If, also, suffocation is imminent, there may remain 
no alternative but a resort to tracheotomy or to laryngotomy. 

Indeed, one of these operations ought, we think, to be resorted to in 
all cases in which emphysema is prominent. Dr. William Hunt, of 
the Pennsylvania Hospital, in his excellent paper on " Fractures of the 
Larynx and Ruptures of the Trachea," in which he has arranged a 
tabular synopsis of twenty-nine cases, says that of twenty-seven cases 
ten recovered and seventeen died. Of eight cases in which tracheo- 
tomy was performed, but two died. In the four cases in which re- 
covery took place without an operation no mention is made of bloody 
expectoration or of emphysema. 1 

As to a "reduction" of the fragments by manipulation, I believe it 
will be found generally, if not always, impracticable. Whatever dis- 
placement exists must be mostly inwards, and we can have no means 
of forcing them again outwards. Nor, if once replaced, do I see any 
reason to suppose that they would not become immediately displaced. 

Chelius has suggested the propriety, in such cases, of cutting open 
the coverings of the larynx freely in the median line, and, after stanch- 
ing the bleeding, proceeding at once to divide the larynx itself in its 
whole length, and then replacing the broken cartilages. 2 The pro- 
cedure has an aspect of severity, but I can well conceive of circum- 
stances which would justify its adoption ; not, however, so much for 
the purpose of replacing the cartilages, as for the purpose of arresting 
a fatal internal hemorrhage, and of giving a free admission of air to the 
lungs. If this operation were to be practiced, the wound ought to be 
left open for a sufficient length of time to allow of the subsidence of 
the inflammation, and then permitted to close with such precautions as 

1 Hunt, Amer. Journ. Med. Sci., April, 1866. 

2 System of Surgery, Philadelphia ed., vol. i, p. 581, 1847. 



146 



FRACTURES OF THE VERTEBRA. 



experience teaches are usually necessary after the windpipe has been 
opened. 

Active antiphlogistic measures, combined with fomentations to the 
neck, so far as these latter are found to be agreeable and practicable, are 
important measures, and not to be overlooked in the general plan of 
treatment. 

My own patient, also, found small pieces of ice, permitted slowly to 
dissolve in the mouth, very grateful ; but he preferred very much, as 
an external application, the warm fomentations to the cold lotions. 



CHAPTER XV 



FRACTURES OF THE VERTEBRAE. 

It will be convenient to divide fractures of the vertebrae into frac- 
tures of the spinous processes, transverse processes, vertebral arches, 
and bodies. 

§ 1. Fractures of the Spinous Processes. 

Fractures of the spinous apophyses, independent of a fracture of the 
arches, may occur at any point of the vertebral column ; and they may 
be occasioned by a blow received upon either side of the spinal column ; 
or by a force directed from above or from below. 

Symptoms and Pathology. — These accidents may be recognized by 
the lively pain at the point of fracture, produced especially when the 
patient bends forwards, which position renders the skin and muscles 
tense and drives the fragments into the flesh ; by the swelling, tender- 
ness, and discoloration; but chiefly by the lateral displacement of the 
broken process, and the mobility. 

Duverney met with a fracture of two of the processes in the same 
person, and which could only be recognized by the mobility, since, as 

the autopsy proved, there was no dis- 
placement. Nor would it be surprising 
if the displacement was absent in a ma- 
jority of these accidents, inasmuch as the 
attachment of the ligaments from above 
and below with the strong and short 
muscles upon either side, must prevent a 
deviation in any direction until these 
tissues were more or less torn. Sir Astley 
Cooper mentions a case in which, how- 
ever, such lacerations did occur, and the 
lateral deformity was quite conspicuous. 

A boy had been endeavoring to sup- 
port a heavy weight upon his shoulders, 
when he fell bent double. Immediately 
he had the appearance of one suffering 
under a distortion of the spine of long 
standing. Three or four of the processes were broken off, and the cor- 



Fig. 37. 




Fracture of the spinous process. 



FRACTURE OF THE SPINOUS PROCESSES. 147 

responding muscles were detached so as to allow the processes to fall 
off to the opposite side. There was no paralysis, and he was soon dis- 
charged with the free use of his limbs, but the deformity remained. 1 

If the fragment is thrown directly downwards, as it possibly may be, 
especially in the cervical or lumbar region, yet not without a rupture 
of the supraspinous ligaments, or of the ligamentum nucha?, then the 
displacement will be more difficult to detect, and it may require some 
more care not to confound it with a fracture of the vertebral arch or of 
the plates from which the spinous processes arise. The process not 
being felt in its natural position, nor upon either side, it may seem to 
have been forced directly forwards, when in fact it is only thrown 
downwards towards its fellow. The danger of error in the diagnosis 
will be increased when to these conditions are added paralysis of those 
portions of the body which are below the seat of the fracture, and 
which, in this case, may be the result of an extravasation of blood or 
of simply a concussion of the spinal marrow. Nor do I think it would 
be possible now to determine positively whether it was simply a frac- 
ture of a spinous process, of the arch, or of the body itself of the ver- 
tebra. In case, however, the paralysis results from concussion, the fact 
.will in most cases soon become apparent by a return of sensation and 
of the power of motion. 

Prognosis. — Hippocrates affirmed that here, as in fractures of other 
spongy bones, the union took place speedily. It is quite probable that 
this venerable father of surgery has stated the fact correctly, and yet 
in the only example known to me where the condition of this process, 
as proved by dissection, has been carefully stated, the fragment had not 
united by bone at all. This is the case related by Sir Astley Cooper 
as having been examined by Mr. Key. A subject was brought into 
the dissecting-room, in which one of the processes had been broken, 
and, on dissection, a complete articulation was found between the 
broken surfaces, which surfaces had become covered with a thin layer 
of cartilage. The false articulation was surrounded with synovial 
membrane and capsular ligaments, and contained a fluid like synovia. 2 

Ordinarily the displacement continues, whatever treatment may be 
adopted ; but Malgaigne says he has seen one instance in which the 
twelfth dorsal spine, being broken and displaced laterally, resumed its 
place spontaneously after a few days. Aurran mentions a similar ex- 
ample. 3 

Treatment. — If in any case it should be found possible to act upon 
the fragment, an attempt might be made to press it into place, and to 
retain it there by means of a compress and bandage ; but even this 
would not be admissible so long as any doubt remained whether it was 
not a fracture of the vertebral arch, since, if it were, any attempt to 
restore the bone to place by pressure would be likely to drive it more 
deeply upon the spinal marrow. Yet what need is there of surgical 
interference of any kind ? If the apophysis remains displaced it can- 
not result in any serious, perhaps we may say in any appreciable de- 

1 Sir Astley Cooper, op. cit., p. 459. 2 lb., p. 459. 

3 Malgaigne, op. cit , p. 412. 



148 FRACTURES OF THE VERTEBRiE. 

formity. The surgeon has therefore only to lay the patient quietly in 
bed and in such a position as he finds most comfortable, enjoining upon 
him perfect rest, and employing such other means as may be proper to 
combat inflammation. 

\ 2. Fractures of the Transverse Process. 

A fracture of a transverse process can scarcely occur except as a con- 
sequence of a gunshot wound. Dupuytren relates a case of this kind 
in which the ball had penetrated the transverse process of the second 
cervical vertebra. The man bled very little at the time, and his symp- 
toms progressed favorably for ten days ; after which secondary haemor- 
rhage occurred, of which he ultimately died. The autopsy showed 
that the vertebral artery had been injured, and that the inflammation 
of its coats being followed by a slough, caused his death. 1 

I have also elsewhere reported the case of Charles Harkner, of 
Buffalo, N. Y., who was shot with a pistol on the 21st of Jan., 1851. 
I did not see him until the following day. The ball had entered the 
chin, a little to the left side and below the inferior maxilla, but its 
place of lodgment could not be discovered. He lay with his face con-, 
stantly turned to the right. The left side of his neck was swollen and 
crepitant ; the left arm and leg were paralyzed ; he slept most of the 
time, but could be easily aroused, and when aroused he seemed to be 
conscious, but was unable to speak. By signs he indicated to us that 
he was suffering no pain. He gradually sank, without haemorrhage, 
and died in thirty-six hours from the time of the receipt of the injury. 

The autopsy, made four hours after death, enabled us to trace the 
wound from the chin, through the left ala of the thyroid cartilage, and 
also through the roots of the transverse process of the fourth cervical 
vertebra; immediately behind which, lying imbedded in the muscles, 
was the bullet. The cavity of the tunica arachnoides contained con- 
siderable serous effusion. 

The emphysema in the neck was occasioned, no doubt, by the wound 
of the larynx, the ball having opened freely into its cavity. This cir- 
cumstance also explained the aphonia ; but the immediate cause of his 
death seems to have been arachnoid effusion as a result of meningeal 
inflammation. 

The symptoms arising from this accident can only refer to the com- 
plications, since a mere fracture of the process is not likely to present 
any peculiar signs which could be recognized. Concussion or bloody 
effusion may take place so as to occasion more or less paralysis, or, at 
a later period, inflammation and its consequent effusions may give rise 
to the same phenomenon. 

In itself considered, and independent of these complications, it is 
sufficiently trivial, but inasmuch as it has not been known to occur 
except from gunshot wounds, nor is it likely to occur except from pen- 
etrating wounds of some kind, the accident must always be regarded 
as exceedingly grave, if not actually fatal. 

1 Dupuytren, Diseases, etc., of Bones, Syd. ed., p. 360. 



FRACTURES OF THE VERTEBRAL ARCHES. 



149 



As to the treatment, nothing but strict rest and antiphlogistic rem- 
edies can prove of any service. 



Fig. 38. 




Fracture of the vertebral arch. 



\ 3. Fractures of the Vertebral Arches. 

The vertebral arches, upon which both the spinous and transverse 
processes have their principal support, may be broken at any point of 
their circumference, by a blow received upon the spinous process ; but 
generally it is the lamellar portion, or 
the "vertebral plate" which gives w 7 ay 
rather than the neck or pedicle of the 
arch ; and in all of the cases recorded the 
plates have been broken upon both sides. 

On the first of May, 1851, during a 
violent storm of wind and rain, a balus- 
trade fell from the top of a high build- 
ing, striking a man named John Larkin, 
who was about forty years of age, upon 
the back of his head and neck. He fell 
to the ground instantly, and did not 
again move his feet or legs, although he 
never lost his consciousness until he died. 
I found the bladder paralyzed also, and 
his left arm, but his right arm he could 
move pretty well. He conversed freely up to the last moment, and 
said that he was suffering a good deal of pain, which was always 
greatly aggravated by moving. His death took place thirty-six hours 
after the receipt of the injury. 

Dr. Hugh B. Vandeventer, who was the attending surgeon, made a 
dissection on the following day in my presence, which disclosed the 
fact that the plates of the sixth cervical vertebra were broken upon 
each side, and that the spinous process, with a small portion of the arch 
attached, was forced in upon the spinal marrow. There was no blood 
effused or serum at this point, but about one ounce of serum was found 
in the cavity of the tunica arachnoides at the base of the brain. The 
bodies of the vertebras w 7 ere not broken. It w r as our opinion, therefore, 
that the immediate cause of his death was the direct pressure of the 
spinous process. 

In the case related by Prout, of Alabama, the man having died 
within forty- eight hours after the receipt of the injury, the arch of the 
fifth cervical vertebra was found to be broken in three places, and the 
spinous process was driven in upon the spinal marrow. There was a 
slight effusion of blood between the sheath of the spinal marrow and 
the bone, and a considerable effusion between the sheath and the cord. 
There was no material lesion of the cord or of its membranes, and the 
body of the bone was neither broken nor dislocated. 1 

It is probable, also, that in the following example the arch was 



1 Prout, Amer. Journ. Med. Sci., Nov. 1837 r vol. xxi, p. 276, from Western Journ. 
of Med. and Phys. Sci. 



150 FRACTURES OF THE VERTEBRA. 

broken, but that the force of the blow having been somewhat oblique, 
the process was but little if at all thrown in upon the spinal marrow. 

R. L., of Erie County, N. Y., aged about forty years, was thrown 
from a loaded wagon in February of 1851, striking, as he thinks, upon 
the back of his neck. He was stunned by the injury, and remained 
insensible several hours ; on the return of consciousness, he found that 
his lower extremities and bladder were paralyzed. During four weeks 
his bladder had to be emptied by a catheter. Nine months after the 
injury was received he consulted me, and I found the spinous process 
of the last cervical vertebra pushed over to the left side. His head 
was strongly bent forwards, and he was unable to straighten it. He 
could walk a few steps, but not without great fatigue ; and he suffered 
almost constant pain in his lower extremities, accompanied with exces- 
sive restlessness and watchfulness, for which he was obliged to take 
morphine in large quantities. 

In the case related by Alban G. Smith, of Kentucky, to which I 
shall refer again presently, the deviation was lateral, and so also in 
Ollivier's case, mentioned by Malgaigne. 

Symptoms. — We can imagine a case of fracture of the vertebral arch, 
with a lateral displacement only, in which the symptoms might not 
differ essentially from a simple fracture of the spinous process; and it 
is quite possible that some of the cases which have been supposed to 
be examples of this latter accident, and in which a speedy recovery has 
taken place, were really examples of fracture of the arches ; yet it 
must be admitted that such a fortunate result is only possible, since 
the arches can hardly be broken without communicating a severe con- 
cussion to the marrow, nor without lacerations, inflammation, and effu- 
sions, which will be most certain to produce compression and paralysis, 
and probably death. 

If, however, it is possible for us to confound a fracture of the process 
with a fracture of the arches, it is still more possible for us to confound 
a fracture of the arches with a fracture of the bodies of the vertebrae. 
If, as is usually the fact, the process, in case of a fracture of the arch, 
is less prominent than natural, and that portion of the body receiving 
its nervous supply from below this point is paralyzed, we may have 
reasons to believe that the arch is broken and the process driven in 
upon the spine; but dissections have shown that in many of these 
cases, or in most of them, indeed, the bodies of more or less of the 
vertebrae are broken also, and in still other cases the bodies were alone 
broken. 

If, as in the case mentioned by Ollivier, we can feel the plates move 
separately, the diagnosis might be made out, so far at least as to deter- 
mine that the plates were broken ; but we should be still unable to say 
that the bodies of the vertebrae were not broken also. 

Something perhaps may be inferred from the direction and manner 
of the blow which has produced the fracture. Thus, a fall upon the 
top of the head would most often produce a comminution of the bodies 
by crushing them together, while a blow upon the back could scarcely 
break one of the vertebrae without breaking the corresponding arch 
also. We might thus be led to infer, in the first instance, that the 



FRACTURES OF THE VERTEBRAL ARCHES. 151 

arches were not broken ; and, in the second instance, if we could con- 
vince ourselves that the -arches were not broken, we might rest pretty 
well assured that the bodies were not. 

In the case related by Prout, there was no external mark of injury 
over the point of fracture, but a distinct crepitus was perceptible on 
pressure. 

Treatment. — If the fragments are not displaced, nothing but rest and 
a cooling regimen are indicated ; but if they are forced in upon the 
marrow, an important question is presented, and which has received 
from different surgeons different solutions. Shall an effort be made to 
reduce the fragments ? and if so, by what means shall the indication be 
attempted ? 

It will be remembered that in nearly all of these cases we must re- 
main in doubt, even after the most careful examination, as to the actual 
condition of the fracture. It may be that what we suppose to be a 
fracture of the arch is only a fracture of the apophysis, or that on the 
other hand, it is a fracture of the body of the bone itself; and if we are 
expert enough to make out clearly a fracture of the arch, it is not pos- 
sible for us to say that the body is not broken also, indeed it is quite 
probable that it is broken. With a diagnosis so uncertain, can we 
ever find a justification for surgical interference? Mr. Cline and Mr. 
Cooper thought that we might. According to them, the case presents 
in no other direction a point of hope or encouragement. Death is 
inevitable, sooner or later, if the fragment is not lifted, and we can 
scarcely make the matter any worse by interference. If it proves to 
be a fracture of the apophysis, as happened to be the case in a patient 
upon whom Sir Astley operated, 1 our interference was unnecessary, but 
it has done no harm. If the body of the bone is broken, the operation 
affords no resources, but the patient is probably beyond suffering dam- 
age at our hands. If the diagnosis is correctly made out and the arch 
only is broken, and if, as was the fact in the case of Larkin already 
mentioned, there is no bloody effusion, or laceration of the membranes 
or of the marrow, and if the concussion was not sufficient to determine 
much inflammation of the cord, then it would seem possible that an 
operation might save the patient. 

Paulus JEgineta first suggested that the compressing fragments 
ought to be removed by excision; and in 1762 Louis removed from a 
man who had received a gunshot wound in his back, after the lapse of 
five days, several loose pieces of bone belonging to the arch of the 
vertebra, and the patient recovered, but not without a partial paralysis 
of his lower extremities. Of course nothing could be more rational 
or simple than this procedure, adopted by Louis, in any case of an 
open wound, where the fragments could be easily reached; but the 
younger Cline was the first, in the year 1814, to put into practice the 
more ancient suggestion of Paulus iEgmeta, namely, to attempt the 
removal of the fragments in a case of simple fracture. He made an 
incision upon the depressed bones as the patient was lying upon his 
face, raised the muscles covering the spinal arch, removing, by means 

1 Chelius's Surgery, Amer. ed., note by South, vol. i, p. 592. 



152 FRACTURES OF THE VERTEBRAE. 

of a circular saw, chisel, mallet, and trephine, etc., the spinous processes 
of the eleventh and twelfth dorsal vertebra?, and the arch of one of the 
vertebrae. The patient was in no manner relieved, and died on the 
fourth day after the receipt of the injury and the third after the opera- 
tion. 1 Mr. Oldknow repeated this operation in 1819 in a case of frac- 
ture of the arch of the seventh vertebra. The patient died on the 
sixth day. 2 In 1822, Mr. Tyrrell operated at St. Thomas's Hospital 
on a man who had been injured four days previously, removing the 
spinous processes of the twelfth dorsal and first lumbar vertebra. The 
operation was accomplished with considerable difficulty, and resulted 
in only a partial return of sensibility. He died on the thirteenth day 
after the operation. 3 In 1827, Tyrrell operated a second time, and 
death resulted on the eighth day. 4 On the 30th of August, 1824, Dr. 
J. Rhea Barton, of Philadelphia, operated upon a man who had been 
received into the Pennsylvania Hospital twelve days before, with a 
fracture of the arch of the seventh dorsal vertebra. On the third day 
he was attacked with a violent chill, and death took place twelve hours 
after. The dissection showed about half a gallon of blood in the pos- 
terior mediastinum, and bloody effusion existed along the whole length 
of the spinal canal. 5 The patient whom Laugier trephined at the base 
of the spinous process of the ninth dorsal vertebra, died on the fourth 
day. 6 The operation has been repeated unsuccessfully by Wickham, 
Attenburrow, Holscher, Heine, and Roux. 7 

February 5th, 1834, Dr. David L. Rogers, of New York, operated 
upon a man who had fallen two days before, breaking the arch of the 
first lumbar vertebra, and forcing the spinous process upon the cord. 
This man died on the eighth day. 8 

In 1854, Dr. Blackmail, of Cincinnati, operated, his patient dying 
on the fourth day. During the same year also, Dr. B. removed a por- 
tion of the sacrum for an injury of four years' standing, with no bene- 
fit. 9 In 1858, Dr. Stephen Smith, of Bellevue, removed the arch of 
the tenth dorsal vertebra, death occurring soon after. 10 December 29th, 
1857, ten days after the receipt of the injury, Dr. J. C. Hutchinson, 
of Brooklyn, operated upon a man at the City Hospital, Brooklyn, re- 
moving the spinous processes of the eighth, ninth, and tenth dorsal 
vertebrae, with the posterior arch of the latter. The patient survived 
the operation ten days. 11 Ballingall says a Dr. Blair has operated suc- 
cessfully, but no particulars are given. 

Dr. H. A. Potter, of Geneva, N. Y., informs us that he has operated 

1 Cline, Chelius's Surgery, Amer. ed., vol. i, p. 590. 

2 Sir A. Cooper on Disloc. and Frac., Amer. ed., 1851, p. 479. 

3 Sir A. Cooper's Loc., by Tyrrell, 3d Amer. ed., 1831, vol. ii, p. 17. 

4 Med.-Chir. Kev., vol. x, p. 601. 

5 Barton, Godman's cd. of Sir A. Cooper on Disloc., etc., p. 421. 

6 Malgaigne, Amer. ed., p. 341. 

7 Cheiius's Surgery, Amer. ed., vol. i, p. 590. Also, Velpeau's Op. Surgery, 1st 
Amer. ed., vol. ii, p. 737. 

8 Rogers, Amer. Journ. M>d. Sci., May, 1835. 

9 Velpeau's Surgery, Blackman's ed., vol. ii, p. 392; also, Dr. Hutchinson's 
Paper, Trans N Y. St Med. Soc, 1861. 

10 New York Journ. Med., 1859, p. 87. 

11 Hutchinson, Trans. N. Y. Med. Soc, 1861, p. 93. 



FRACTURES OF THE VERTEBRAL ARCHES. 153 

three times. In the first case he states that he removed the posterior 
portion of the three lower cervical vertebrae. The patient died on the 
fourth day. In the second case the doctor removed the spinous pro- 
cesses of the fifth and sixth cervical vertebrae, and the entire posterior 
arch of the fifth. The sheath was not broken, " but the cord was much 
injured." There was almost complete paralysis of the extremities, and 
this condition was not remedied by the operation. Three years later, 
the patient being still alive, but only a very slight improvement having 
taken place, Dr. Potter " removed the fourth, sixth, and seventh cervi- 
cal vertebrae." (We presume he intends to say the " posterior arches.") 
At the time of the report, Jan. 1863, there was no further improvement. 
Finally, the doctor reports a completely successful case. The injury 
was of " five months' standing." 1 Packard says, in a note to his trans- 
lation of Malgaigne, that Dr. Potter operated on a case of three months' 
standing, and the patient died on the eighteenth day. I suppose this 
to be the same case. 

These are all of the cases of which we have any information in 
which this operation has been made, and they have all, excepting the 
two cases reported by Potter and the one by Blair, terminated fatally 
in a very few days. The case reported by Alban G. Smith, of Ken- 
tucky, is not related in such a manner as to enable us to make use of 
it safely, nor is it stated how long the patient survived the operation ; 
Gibson says it gave no permanent relief. The example mentioned by 
an English w r riter is equally unreliable, inasmuch as it is given only 
upon rumor, and but a " few months " had elapsed since the operation 
was performed. It was said to have been made in the year 1838, by 
a surgeon of the name of Edwards, in South Wales ; and it was affirmed 
that the compression was relieved and that the patient "did well." 2 
So unique a case would certainly have found before this an ample con- 
firmation. Indeed, w T e must say that none of the cases reported as 
successful give any evidence of authenticity. 

Experience, then, seems to have shown that w r e have little or nothing 
to expect from this surgical expedient ; and, notwithstanding the strong 
hope expressed by Sir Astley Cooper that Mr. Cline's operation might 
hereafter prove a valuable resource, and contrary to the conclusions which 
w r e in common with many other surgeons had drawn from the anatom- 
ical relations of these parts, we are compelled reluctantly to declare 
that the expedient is scarcely worthy of a trial. To the same conclu- 
sion also many of the most distinguished surgeons have arrived, among 
whom w r e may mention, as especially entitled to confidence, Brodie, 
Liston, Alexander Shaw, Malgaigne, and Gibson. 

What more can be said of the attempt to raise the depressed bone 
by seizing the spinous process with the fingers, or with a pair of strong 
hooked forceps passed through the skin, or finally, if this cannot be 
done, by laying bare both sides of the process and seizing upon it with 
a pair of firm tenacula ? This is the alternative presented to Malgaigne, 
and which he ventures to recommend as deserving a trial. In the ab- 

1 Amer. Med. Times, Jan. 10, 1863. 

2 Edwards, British and Foreign Med. Rev., 1838, p. 162. 

11 



154 FRACTURES OF THE VERTEBRAE. 

sence, however, of any testimony in its favor, beyond the mere rational 
argument adduced by this distinguished writer, we must waive any 
farther consideration of the subject; only expressing our conviction 
that it will be found, after a fair trial, as useless and as inexpedient as 
the more severe operation of Cline. 

Jeffries Wyman, of Boston, has met with eleven examples of frac- 
tures of the vertebral arches occurring in the fourth or fifth lumbar 
vertebrae between the lower articulating and the transverse processes, 
all of them old ununited fractures. He has also met with the same 
fracture once in the third lumbar vertebra. The frequency of this 
peculiar form of fracture in this region Dr. Wyman ascribes to the 
fact that the upper and lower articulating processes are widely sepa- 
rated from each other, and connected only by a narrow neck, in which 
respect they contrast very strongly with the dorsal vertebrae ; and he 
supposes that the fractures may be caused by either a forcible bending 
of the body backwards, or by the shock resulting from a fall from a 
height in which the force of the concussion is conveyed downwards 
through the pelvis.. In. no case has the existence of this fracture been 
recognized during life> nor is it probable that its occurrence would 
cause any marked symptoms unless it had been caused by a blow re- 
ceived directly from behind. 1 ' 

As to the therapeutical treatment of the various symptoms belong- 
ing to these accidents, and in relation to the prognosis, the remarks 
which we shall make will be found equally applicable to fractures of 
the bodies of the vertebrae, and we shall reserve the consideration of 
these topics for the following section. 

I 4. Fractures of the Bodies of the Vertebrae. 

The same causes which produce fractures of the arches may produce 
also fractures of the bodies of the vertebrae, that is, blows received 
directly upon the extremities of the spinous processes ; but in these 
cases the arches are generally broken at the same time. 

In other cases the bodies of the vertebrse are broken by falls upon 
the top of the head, by which the vertebrae are not only driven forcibly 
together, but often doubled forwards upon each other ; or the patient 
may have alighted upon his feet or upon his sacrum. 

Reveillon has reported a case of fracture of the fifth cervical vertebra 
from muscular action, which occurred in diving. The man was taken 
out of the water unconscious, and died in a few hours, having declared 
before death that his head did not strike the bottom, although he had 
jumped from a height of seven or eight feet, and the water was only 
three feet deep. 2 The statement of the sufferer, under such circum- 
stances, could not really possess much value, and we think we see good 
reasons to suppose that he was mistaken. South also relates a case of 
fracture of the fourth and fifth cervical vertebrae occasioned by diving, 
in which it was supposed that the fracture was caused by the concussion 
of the head upon the water. 3 

1 Wyman, Boston Med. and Surg. Journ., Aug. 12, 1869. 

2 Reveillon, Chelius's Surg., note by South, vol. i, p. 584. 

3 South, ibid., p. 583. 



FRACTURES OF THE BODIES OF THE VERTEBRA. 155 

Malgaigne says the spine bends at three principal points ; comprised, 
the first between the third and seventh cervical vertebrae, the second 
between the eleventh dorsal and second lumbar, the third between the 
fourth lumbar and the sacrum ; and that a majority of the fractures of 
the vertebrae occur at these points of flexion. He makes an argument 
from this also that these fractures " are generally the result of counter- 
strokes, as the effect of forcible flexion of the column either forwards 
or backwards." Malgaigne observes, moreover, that dislocations follow 
the same rule. 

The direction of the line of fracture varies greatly in the different 
examples which we have seen ; some are crushed, and more or less 
comminuted. In some cases a narrow piece is chipped from the mar- 
gin, others are broken transversely, and others obliquely. In oblique 
fractures the line of the fracture is generally from behind forwards, 
and from above downwards. Malgaigne thinks that a crushing or 
comminution can only occur from a forcible flexion forwards ; but I 
have seen at least one example in which this was not the fact ; the 
patient having fallen so as to strike with the back of his neck upon 
an iron bar. This was the case of the sailor, to which I shall again 
refer more particularly. 

The upper fragment is almost always that which suffers displace- 
ment ; sometimes being simply driven downwards, and thus made to 
penetrate more or less the lower fragment ; at other times, as in certain 
transverse fractures, it is only displaced forwards, and in still other 
examples, where the fracture is oblique, the upper fragment is displaced 
both downwards and forwards. 

In the first and last of these examples the spine becomes bent for- 
wards at the point of fracture, producing an angle of which the most 
salient point posteriorly is represented by the 
extremity of the spinous process belonging 
to the broken vertebra ; in the second example 
the spinous process of the broken vertebra is 
depressed, and the process of the vertebra 
next below is relatively prominent. 

In a pretty large proportion of cases also 
the fracture of the body of the vertebra is 
complicated, as we have already stated, with 
a fracture of the arches, in some instances 
with a fracture of the oblique processes, and 
with a dislocation. 

Symptoms. — Severe pain at the seat of frac- 
ture, felt especially when the part is touched 
or the body is moved, tenderness, swelling, 
ecchymosis, occasionally crepitus, a slight oblique fracture of the bo je p 
angular distortion of the spine, or simply a of a vertebra. 

trifling irregularity in the position of the pro- 
cesses, and paralysis of all the parts whose nerves take their origin 
below the fracture, are the usual signs of the accident. 

The paralysis may be due to the mere pressure of the displaced 
fragments, but it is much more often due to a severe and irreparable 




156 FRACTURES OF THE VERTEBRA. 

lesion of the cord itself. I have, in one instance, seen the cord almost 
completely separated at the point of fracture, although the displacement 
of the fragments was inconsiderable. 

Accompanying the paralysis of the bladder, there has been generally 
observed an alkaline state of the urine, and subacute inflammation of 
the coats of the bladder. Priapism is present in a certain proportion 
of cases. 

Those who die immediately seem to be asphyxiated ; while those 
who die later seem to wear out from general irritation, this condition 
being frequently accompanied with an obstinate diarrhoea and vomit- 
ing. A few become comatose before death. 

It will be seen, moreover, that a certain proportion finally recover; 
but scarcely ever are all the functions of the limbs and of the body 
completely restored. 

We shall render this part of our description of these accidents more 
intelligible if we regard them as they occur in the various portions of 
the spinal column, since the symptoms, prognosis, and treatment have 
reference mainly to the point at which the fracture has occurred. 

1 . Fracture of the Bodies of the Lumbar Vertebras. 

The spinal cord terminates, in the adult, at the lower border of the 
first lumbar vertebra, but in the child at birth it extends as low as 
the third lumbar vertebra. The remainder of the vertebral canal is 
occupied by the leash of terminal nerves, called collectively the cauda 
equina. 

The nerves which emerge from the intervertebral foramina below 
the fourth and fifth lumbar vertebrae, unite with the sacral nerves to 
form a plexus which supplies the sphincter and levator ani, the perineal 
muscles, the detrusor and accelerator urinse, the urethra, the glans 
penis, and a great proportion of the lower extremities. It will be 
apparent, therefore, that a fracture, with displacement, of even the last 
vertebra of the column, involves the possibility of more or less paralysis 
of all those parts supplied by this plexus, and that in proportion as 
the fracture is higher in the vertebral column, will the probability of 
additional complications be increased. In other words, in addition to 
the more or less complete loss of function in the organs supplied by 
the ilio-sacral plexus, there will probably be associated loss of function 
in other organs, supplied from sources above this point of the vertebral 
canal. 

A fracture, however, of the bodies of the fourth or fifth lumbar 
vertebra, produced by a direct blow, is exceedingly rare, owing to the 
protection which it receives from the alse of the pelvis. 

Dr. Alexander Shaw has reported four cases of fracture below the 
second lumbar vertebra, which were unaccompanied with any degree 
of paralysis, and which were followed by speedy recovery, 1 a circum- 
stance which he ascribes to the fact that the cauda equina is composed 
of nerves possessing considerable firmness, and suspended loosely to- 

1 Shaw, London Med. Gaz., vol. xvii. 



FEACTURES OF THE BODIES OF THE VERTEBRAE. 157 



gether ; for this reason they escape pressure by slipping among them- 
selves, and suffer less injury from the same amount of compression than 
the medulla spinalis. 

In the two following cases the results were less fortunate, yet recov- 
eries seem to have taken place. 

A boy was admitted into St. George's Hospital, in September, 1827, 
with a fracture and considerable displacement of the third and fourth 
lumbar vertebrae, the displacement being sufficient to cause a manifest 
alteration in the figure of his spine. His lower limbs were paralytic. 
An attempt was made to restore the displaced vertebrae, but it was 
attended with only partial success. At the end of a month he had 
slight involuntary motions of the lower extremities, and at the same 
time he began to recover the power of using them voluntarily. Three 
or four months after the receipt of the injury he left the hospital, and 
the history of his case was interrupted at this date. 1 

Dr. Thompson, of Goshen, N. Y., reports also a fracture of either 
the third or fourth lumbar vertebra, followed by recovery. The patient 
fell from the roof of a house, striking first upon his feet and then upon 
his buttocks. This occurred in October, 1853. The usual signs of a 
fracture were present, such as paralysis, etc. ' A bed-sore formed above 
the top of the sacrum, and a piece of bone exfoliated, which seemed to 
belong to the last lumbar vertebra. He was confined to his bed seven 
months. After eighteen months he began to 
use crutches. At the end of about three years 
all improvement ceased, at which time he could 
not quite stand alone ; yet with the aid of ap- 
paratus he was able to get about the country 
and vend books, prints, etc. This was also his 
condition one year later. 2 

A patient in Guy's Hospital, under Mr. Key, 
with a fracture of the first lumbar vertebra, 
lived one year and two days. On examination 
after death it was ascertained that bony union 
had occurred between the fragments, and that 
the spinal marrow was completely separated at 
the point of fracture. 3 

Mr. Harrold relates a case of fracture of the 
first and second lumbar vertebrae, in which the 
patient survived the accident one year lacking 
nine days ; death having resulted finally from 
a sore on the tuberosity of the ischium and dis- 
ease of the bone. After death it was ascertained that the fracture had 
united by bone, and that the spinal marrow was almost completely cut 
in two, the divided extremities being enlarged and separated nearly an 
inch from each other. 4 



Fig. 40. 




Key's case of fracture of the 
first lumbar vertebra. 



1 Brodie, Sir Ast. Cooper on Disloc., op. cit., p. 471. 

2 Thompson, Araer. Journ. Med. Sci., Oct. 1857. Lente's paper. 

3 Key, A. Cooper on Disloc, etc., op. cit., p. 467. 

4 Harrold, A. Cooper, op. cit., p. 464. 



158 FRACTURES OF THE VERTEBRA. 

2. Fractures of the Bodies of the Dorsal Vertebra 3 ,. 

In these examples the same organs are paralyzed as in the fractures 
lower down, in addition to which there is generally considerable dis- 
turbance of the functions of respiration, irregular action of the heart, 
indigestion, accompanied with a tympanitic state of the bowels. 

Dupuytren, who reports several examples of fractures of the dorsal 
vertebrae, has not taken the pains to record the length of time they 
survived the accident except in two instances, both of which were 
fractures of the eleventh vertebra. One died of suffocation on the 
tenth day, and the other on the thirty-second. In Sir Astley Cooper's 
cases, mention is made of a fracture of the twelfth dorsal vertebra, 
which the patient survived fifty-two days, one of the tenth dorsal, 
which terminated fatally in six days, and another of the ninth dorsal, 
which did not result in death until after nine weeks. 

In 1853 Dr. Park man presented to the Boston Society for Medical 
Improvement a specimen of fracture of the fifth dorsal vertebra, the 
bodies of the third and fourth being also displaced forwards, in which 
position they had become firmly ossified. The spinal cord had been 
completely separated, yet the patient survived the accident two months. 1 

Dupuytren has related also two examples of fractures, one of the 
tenth and the other of the last dorsal vertebra, from which the patients 
completely recovered after from two to four months' confinement. 2 A 
similar case is related by Lente, of New York. Barney McGuire, 
having fallen a distance of twelve or fifteen feet upon his back, was 
found with nearly complete paralysis of his lower extremities and of 
his bladder. Swelling existed over the lower dorsal vertebra?, and this 
point was very tender. Subsequently, when the swelling subsided, the 
prominence of the spinous processes of the tenth and eleventh dorsal 
vertebrae put the question of a fracture beyond doubt. Gradually, 
under the use of cups, strychnia, mineral acids, laxatives, buchu, and 
electricity, his symptoms improved. In six months he was able to walk 
about the streets, and four years after the accident he was employed in 
a foundry under regular wages, being able to stand fifteen or twenty 
minutes at a time, and to walk half a mile without resting. At this 
time there remained no tenderness in the spine, but the projection of 
the process was the same as at first. 3 

3. Fractures of the Bodies of the five lower Cervical Vertebra?. 

We shall now have added to the symptoms already enumerated, 
paralysis of the upper extremities, greater embarrassment of the respira- 
tion, and more complete loss of sensation and volition in the lower part 
of the body. In general, also, the eyes and face look congested, owing 
to the imperfect arterialization of the blood, and death is more speedy 
and inevitable. 

In ten recorded examples of fractures of the five lower cervical ver- 

1 Parkman, New York Journ. Med., March, 1853, p. 286. 

2 Dupuytren, op. cit., pp. 356-7. 

3 Lente, Amer. Journ. Med. Sci., Oct. 1857, p. 361. 



FRACTURES OF THE BODIES OF THE VERTEBRA. 159 

tebrse which I have been able to collect, one died within twenty-four 
hours, four in about forty-eight hours, one in eleven days, one lived 
fifteen weeks and six days, one about four months, one fifteen months, 
and one, reported by Hilton, survived fourteen years. 1 The most com- 
mon period of death seems, therefore, to be about forty-eight hours after 
the receipt of the injury. 

The example of the patient who survived the accident fifteen weeks 
and six days, is recorded by Mr. Greenwood, of England. A woman, 
Mary Vincent, set. 47, was injured by a blow on the back of her neck, 
but she was not seen by Mr. Greenwood until after eleven days, at 
which time she was breathing with difficulty, occasioned by paralysis 
of the intercostal muscles, respiration being carried on by the diaphragm 
and abdominal muscles alone. This was the extent of the paralysis. 
There seemed to be a depression opposite the fourth and fifth cervical 
vertebrae, and pressure at this point occasioned universal paralysis, as 
did also the action of coughing and sneezing. About three weeks after 
the accident, she attempted for the first time to move in order to have 
her clothes changed, when she was immediately seized with paralysis 
in the right arm and hand. After this she lost her appetite, had fre- 
quent attacks of purging, and thus she gradually wore out. 2 

The patient who survived about four months was admitted into Hdtel 
Dieu, under the care of Dupuytren, in 1825, on account of a fracture 
of the fourth cervical vertebra, caused by a fall on the back of his neck, 
and suffering under paralysis of the bladder and extremities. After 
two months and a half of entire rest, he was convalescent and quitted 
the hospital, with only slight weakness in his left leg, and with his head 
a little bowed forwards. In returning from a long walk he fell para- 
lyzed, and remained in the open air all night. From this time he con- 
tinued to fail, and died thirty-four days after the second fall. On ex- 
amination after death, the body of the vertebra was found to be broken, 
and also the processes of the fifth, allowing the fourth to slip forwards 
and compress the cord. A. true callus existed in front of these bones, 
which looked as if recently broken. The cord itself exhibited an an- 
nular constriction, which Dupuytren conceived to be the seat of the 
original lesion narrowed by cicatrization. 3 

The following example furnishes a fair illustration of the usual phe- 
nomena which accompany fractures of the third or fourth cervical ver- 
tebra. 

On the 25th of July, 1857, a sailor fell backwards from the wharf, 
striking with the nape of his neck upon a bar of iron. I saw him on 
the following day, in consultation with his attending physician, Dr. 
Edwards. He was lying upon his back, breathing rapidly. His lower 
extremities were completely paralyzed; legs and feet swollen and 
purple; right arm completely paralyzed, and his left partially'; from a 
point below the line of the second rib, there was no sensation whatever ; 
his bowels had not moved, although he had already taken active cathar- 
tics; the urine had been drawn with a catheter; the pulse was slower 

1 Hilton, Lond. Lancet, Oct. 27, 1860. 

2 Greenwood, Sir A. Cooper on Disloc, p. 472. 
s Dupuytren, op. cit., p. 358. 



160 FRACTURES OF THE VERTEBRA. 

than natural, and irregular. He was constantly vomiting. In reply 
to questions, he said that he felt well, articulating distinctly and with 
a good voice. His eyes and face were somewhat congested, but with 
this exception his countenance did not betray the least physical dis- 
turbance. He lived in this condition about forty hours, only breathing 
shorter and shorter, and his consciousness remaining to the last moment. 

In proceeding to examine the spine a few hours after death, and 
before any incision was made, we were unable, upon the most minute 
examination, to detect any irregularity of the processes of the cervical 
vertebrae, or any crepitus; but, on dissecting the neck, we found that 
the arches of the third and fourth vertebrae were broken, and the spin- 
ous processes slightly depressed upon the cord. The bodies of the cor- 
responding vertebrae were comminuted, and the vertebrae above were 
driven down upon them, carrying the processes in the same direction. 
The theca and the spinal marrow were almost completely severed upon 
a level with the fourth vertebra. 

A man residing in Erie Co., N. Y., was thrown backwards suddenly 
from the back end of a wagon, alighting upon the top of his head. Dr. 
Mixer having requested me to see this patient with him, I found the 
symptoms almost an exact counterpart of those which belonged to the 
case which I have just described, except that a crepitus and a mobility 
of the fragments could be distinctly felt in the upper and back part of 
his neck. His death occurred in very much the same manner after 
about forty-eight hours. No autopsy was allowed. We noticed in 
this case, also, that whenever he was turned over upon his face, respi- 
ration almost entirely ceased, but it was immediately restored by lay- 
ing him again on his back. Many other similar examples have from 
time to time come under my notice. 

Strains of the Ligaments and Muscles. — Dupuytren, Sir Astley Cooper, 
South, and other surgeons have related cases simulating fracture, but 
which proved to be strains of the ligaments uniting the cervical ver- 
tebrae, accompanied with more or less injury to the spinal marrow. 
In one instance, I have met with what has seemed to be a strain of the 
ligaments and muscles of the neck, but which presented no symptoms 
of serious injury to the spinal marrow. 

John Neuman, of Canada West, set. 25, fell headforemost from a 
height of fourteen feet, striking upon the top of his head. He was 
taken up insensible, and remained in this condition six hours. When 
consciousness returned, his head was very much drawn backwards, and 
it was impossible to move it from this position. There was no lack of 
sensibility or of the power of motion in his limbs, and all the functions 
of his body were in their natural state; but he has suffered with occa- 
sional severe pains in his arms ever since. The accident happened on 
the twenty-fourth of November, 1857, and he called upon me eight 
months after. His head was then forcibly bent forwards instead of 
backwards, into which position it had gradually changed. In the 
morning he generally was able to erect his head completely, but after 
a few hours it was constantly drawn forwards, as when I saw him. 
There was no tenderness or irregularity over the cervical vertebrae, and 
he was so well as to be regularly employed as a day-laborer. 



FRACTURES OF THE BODIES OF THE VERTEBRA. 161 

Concussion. — Sir Astley Cooper has collected four examples of what 
he terms " concussion of the spinal marrow," all of which recovered 
after periods ranging from a few weeks to many months ; but in only 
one case is it stated that the recovery was complete. 1 Boyer also enu- 
merates three cases of concussion which came under his own observa- 
tion, all of which terminated fatally in a short time. In the first 
example mentioned by Boyer, the autopsy disclosed neither lesion nor 
effusion of any kind ; in the second case, it does not appear that any 
autopsy was made. The third is related as follows : " A builder fell 
from a height of fourteen feet, and remained for some time senseless ; 
and, on recovering from that situation, found that he had lost the use of 
his inferior extremities. He had at the same time a retention of urine, 
an involuntary discharge of the faeces, and some disorder in the function 
of respiration. Death followed on the twelfth day after the accident. 
The body was opened, and the vertebral canal was found to contain a 
sanguineous serum, the quantity of which was sufficient to fill a little 
more than its lower half." 2 No doubt some of the cases reported as 
concussion were only examples of paralysis from extravasation of blood, 
a circumstance which is peculiarly likely to happen as a result of the 
rupture of one of those numerous large vessels which surround the ver- 
tebrae outside of the thecae. It is seldom that the vessels of the cord 
itself give out sufficient blood in these cases to cause compression. 
Possibly examples of compression as a result of extravasation of blood 
may sometimes be recognized by the fact of the gradual approach of 
the paralysis after the lapse of several hours, as has occurred recently 
in a case brought to my notice at the Bellevue Hospital, and in which 
recovery finally took place. 

4. Treatment of Fractures of the Bodies of the Vertebrae when the fracture 
occurs in any 'portion of the column below the Second Cervical. 

In a few instances, I have noticed among the recorded examples of 
fractures of the bodies of the vertebrae, that surgeons have made some 
slight attempt to reduce the fracture, or rather to rectify the spinal dis- 
tortion, generally by the application of moderate extension to the limbs, 
and by laying the patient horizontally upon a hard mattress. But I 
have not been able to discover that in any case the patients have de- 
rived benefit from the attempt, although it has been said occasionally, 
by the gentlemen making the report, that the deformity was slightly 
diminished. Nor am I aware that in any instance the patient has suf- 
fered any damage from the attempt; at. least the reporter has in no 
case thought it necessary to make this observation. I am confident, 
however, that such manipulation can seldom serve any useful purpose, 
and I very much fear that it has been frequently a source of mischief; 
although in cases so generally fatal, it might be very difficult to esti- 
mate with much accuracy the amount of injury done. If by any pos- 
sibility the fragments could be replaced, I know of no means by which 
they could be kept in place ; and in truth we are much more likely to 

1 Sir A. Cooper, op. cit., p. 454. 

2 Boyer, Lecture on Diseases of the Bones, Amer. ed., 1805, p. 55. 



162 FRACTURES OF THE VERTEBRAE. 

increase the penetration of the spinal cord and the general disturbance, 
than to diminish it, by extension or pressure. Moreover, it usually 
inflicts upon the unfortunate sufferer great pain, and for these reasons 
it ought generally to be discouraged. 

I have, however, met with two cases of fracture of the lumbar verte- 
brae, in which relief was afforded by permanent extension. When the 
fracture is below the middle of the vertebral column, extension, if em- 
ployed, should be made by adhesive straps, weights, and a pulley, as 
will hereafter be directed in fractures of the femur ; the counter-exten- 
sion being made by the weight of the body. It will be understood, 
however, that when paralysis exists the ligation of a limb with band- 
ages will expose the patient to great danger of ulceration and sloughing 
at and below the points of pressure, and the amount of extension must 
be very moderate. 

When treating of fractures of the arches of the vertebrae, I took oc- 
casion to call attention to Mr. Cline's operation, occasionally recom- 
mended and practiced in such cases. I was not ignorant, however, 
that Mr. Cline, and several other of the advocates of this operation, had 
recommended it especially for fractures of the bodies of the vertebrae 
when accompanied with displacement. Even Malgaigne has preferred 
to consider the merits of this operation in its relations to these latter 
fractures ; but while lam prepared to admit the propriety of an argu- 
ment as to the value of Cline's operation considered in reference to 
fractures of the arches, I cannot admit its propriety in reference to 
fractures of the bodies of the vertebra?. The proposition appears to me 
too absurd to be entertained for a moment. 

The treatment, then, ought to be, in a great measure, expectant. 
The patient should be laid in such a position as he finds most comfort- 
able, and, as far as possible, the spine should be kept at rest, since the 
most trivial disturbance of the fragments, and even that which may 
cause no pain to the patient, is liable to increase the injury to the 
spine, and prevent the formation of a bony callus. Especially ought 
the surgeon to be careful, while making the examination, not to turn 
the patient upon his face, in which position the spine loses its support 
and a fatal pressure may be produced. The urine should be drawn 
very soon after the accident, and at least twice daily for the next few 
weeks. Indeed, it is a better rule to draw the urine as often as its ac- 
cumulation becomes a source of inconvenience, or whenever the bladder 
fills, which will in some cases be as often as every four or six hours. 
It is especially necessary to attend to those urgent demands of the patient 
during the first few weeks, when the paralysis is most complete gener- 
ally, and the mucous surface of the bladder, already irritated and in- 
flamed by the excessively alkaline urine, suffers additional injury from 
any degree of painful distension of its walls. It is unnecessary to say 
that the frequent introduction of the catheter may itself prove a source 
of irritation, unless it is managed carefully and skilfully. This duty 
ought never to be intrusted to an inexperienced operator. 

I do not see what advantage the surgeon can expect to derive from 
the administration of drastic purgatives, such as full doses of jalap, 
castor oil, or spirits of turpentine, at any period. If in the first in- 



FRACTURES OF THE BODIES OF THE VERTEBRA. 163 

stance the bowels are so completely paralyzed as that they seeni to de- 
mand such violent measures to arouse them to action, we may be quite 
certain that the spinal cord is suffering from a pressure, or from some 
lesion, which these agents have no power to remedy. The bowels may 
possibly be made to act, but it would be difficult to show how this is 
to relieve the suffering cord. So far from affording relief, these meas- 
ures add directly to the nervous irritation and prostration, provoke 
vomiting and general restlessness. It is not desirable, we think, to 
obtain a movement of the bowels during the first few days by any 
means, however gentle. The effort to defecate, and the consequent 
motion, will probably do much more harm than the evacuation can do 
good ; and especially, for the same reason, ought we to avoid putting 
into the stomach anything which will occasion nausea and vomiting. 

After the lapse of a few days, if reasonable hopes begin to be enter- 
tained of a recovery, it will become important to establish regular 
evacuations of the bowels, either by a judicious management of the 
diet, by gentle laxatives, or by enemata. At a still later period, when 
the inflammatory stage is past, and the nerves remain inactive or para- 
lyzed, nothing could be more rational than the employment of strych- 
nia in doses varying from the one-twelfth to the one-eighth of a grain 
three times daily. Nor do I think that any single remedy has more 
often proved useful in my own practice, or in the practice of other sur- 
geons with whom I am acquainted. In order, however, to derive ben- 
efit from this or from any other remedy, it must be continued for a 
long time ; perhaps for a year or more. Electricity, setons, issues, and 
blisters are no doubt also sometimes useful. Care must be taken that 
setons, etc., do not produce bed-sores. Passive motion and frictions, 
good fresh air, and nourishing diet, become at last essential to recovery. 
From an early period, and during the whole course of the treatment, 
great attention should be paid to the prevention of bed-sores, by sup- 
porting all those parts of the body upon which the pressure is consid- 
erable. For this purpose we may employ circular cushions, air-cush- 
ions, and air-beds ; but water-beds are very much to be preferred to 
air-beds as a means of preventing bed-sores. "Water-beds must be 
filled with water of the temperature of 68° Fahrenheit, and they must 
be secured in position by side boards, or a kind of shallow box, the 
sides of which are elevated six or seven inches. Permanent extension 
can be employed upon these beds as well as upon ordinary beds. 
Sometimes a section of a bed, three feet square, is found quite as ser- 
viceable as an entire bed, inasmuch as the back and nates are the only 
parts which are liable to bed-sores. They may be obtained from the 
manufacturers, Hodgman & Co., corner of Nassau Street and Maiden 
Lane, New York City, at prices ranging from $15 to $25. Of late we 
have found the wire-beds, manufactured at 59 Pearl Street, Hartford, 
Conn., excellent substitutes for water-beds. They are less expensive, 
more easily managed, more durable, and admit of a much better regu- 
lation of the temperature. Whether they are quite as efficient in the 
prevention of bed-sores as water-beds, I cannot say positively, but they 
have been much used under my observation at Bellevue and in the 
Hospital for Ruptured and Cripples, and I have seen no bed-sores 
occur where they were in use. 



164 FEACTUKES OF THE VERTEBRJE. 

When sores have formed, they should be treated, if sloughing, with 
yeast poultices, or the resin ointment. I find also the resin ointment 

Fig. 41. 




Wire-bed. 

an excellent dressing for the sores after the sloughs have separated. 
In case the surface is only slightly abraded, simple cerate forms the 
best application. 

2 5. Fractures of the Axis. 

The phrenic nerve is derived chiefly from the third and fourth cer- 
vical nerves. If, therefore, the second cervical vertebra is broken, and 
considerably depressed upon the spinal cord, respiration ceases imme- 
diately, and the patient dies at once, or survives only a few minutes. 
In such examples of fracture of this bone as have not been attended 
with these results, the displacement and consequent compression have 
been inconsiderable, or there has been no displacement at all. 

Mr. Else, of St. Thomas's Hospital, says that a woman in the vene- 
real ward, and who was then under a mercurial course, while sitting in 
bed, eating her dinner, was seen to fall suddenly forwards : and the 
patients, hastening to her, found that she was dead. Upon examina- 
tion of her body, it was discovered that the processus dentatus of the 
axis was broken off, and that the head in falling forwards had driven 
the process backwards upon the spinal marrow so as to cause her death. 1 

Sir Astley Cooper also relates the case of a man who was shot by a 
pistol through the neck, breaking and driving in upon the spinal 
marrow both the " lamina and the transverse process " of the axis. 
He died on the fourth day. 2 

Malgaigne has collected three cases of fracture of the odontoid 
apophysis, all of which were accompanied with a displacement of the 
atlas. The first, reported by Richet, died on the seventeenth day ; the 
second, reported by Palletta, died after one month and six days ; and 
the third, by Costes, lived four months and two weeks. 

Rokitansky says that there is a specimen contained in the Vienna 
Museum, taken from a patient who survived the accident some time, 
although the fragments never united. 

The following case is reported by Parker : 

" The patient, Mr. G. B. Spencer, was a man forty years of age, a 
milkman by occupation, of medium height, nervo-sanguine tempera- 
ment, of active business habits, and capable of great endurance. His 
life was one of constant excitement, and he was addicted to the free 
use' of liquors. He suffered, however, from no other form of disease 

1 Else, Sir A. Cooper on Disloc, etc., op. cit., p. 462. 

2 Sir A. Cooper on Disloc, etc., op. cit, p. 476. 



FRACTURES OF THE AXIS. 165 

than occasional attacks of rheumatism, for which he was accustomed 
to take remedies of his own prescribing, which were generally mercu- 
rials followed by liberal doses of iodide of potassium, ' to work it all 
out of the system/ 

"On the 12th of August, 1852, while driving a 'fast horse ' at the 
top of his speed on the plank road near Bushwick, L. I., he was thrown 
violently from his carriage by the wheel striking against the toll-gate. 
He alighted upon his head and face about fifteen feet from the carriage. 
Upon rising to his feet he declared himself uninjured, but soon after 
complained of feeling faint ; after drinking a glass of brandy he felt 
better, got into his carriage with a friend, and drove home to Riving- 
ton Street in this city, a distance of more than two miles. There was 
so little apparent danger in this case, that no physician was called that 
night. Early on the morning of the following day, Dr. B. was called 
to visit him. He found his patient reclining in his chair, in a restless 
state, and learned that he had suffered considerable pain in the back 
part of his head and neck during the night. He was entirely inca- 
pacitated to rotate the head, which led to the suspicion of some injury 
to the articulations of the upper cervical vertebrae ; but so great a de- 
gree of swelling existed about the neck as to prevent efficient examina- 
tion. There was no paralysis of any portion of the body, his pulse 
was about 90, and his general system but little disturbed. Warm 
fomentations were applied to the neck, and a mild cathartic adminis- 
tered. On the following day there was no particular change in his 
symptoms, but as there existed considerable nervous irritability, tinct. 
hyoscyami was prescribed as an anodyne, and fomentations of hops 
applied locally. On the third day, leeches were applied to the neck, 
and after this the swelling so much subsided, that on the fifth day an 
irregularity was discovered to exist in the region of the axis and atlas, 
which had many of the features of a partial luxation of these vertebrae. 

" At this time he began to walk about the room, having previously 
remained quiet on account of the pain he suffered on moving. He 
persisted in helping himself, and almost constantly supported his head 
with one hand applied to the occiput. He often remarked, if he could 
be relieved of the pain in his head and neck, he should feel well. He 
began to relish his food, and the swelling nearly disappeared at the 
end of a week, leaving a protuberance just below the base of the occi- 
put, to the left of the central line of the spinal column, with a corre- 
sponding indentation. Notwithstanding strict orders to remain quietly 
at home, on the ninth day after the accident he rode out, and in a day 
or two after returned as actively as ever to his former occupation of 
distributing milk throughout the city to his old customers. During 
the following four months no material change took place in his symp- 
toms, although he constantly complained of pain in his head. For 
this period he did not omit a single day his round of duties as a milk- 
man, which occupied him constantly and actively from five o'clock in 
the morning to nearly noon. On the first of November, Prof. Watts 
examined him, and inclined to the opinion that there was a luxation 
of the upper cervical vertebrae. 

"About the 1st of January, 1853, the pains, from which he had 



166 FRACTURES OF THE VERTEBRAE. 

been a constant sufferer, became more severe, and he was heard to 
complain that he could not live in his present condition ; he remarked, 
also, that he had heard a snapping in his neck. After going his daily- 
round on the 11th of January, he complained of feeling cold, and 
afterwards of numbness in his limbs. In the evening he had a chill, 
and complained of a pain in his bowels. He passed a restless night, 
and arose on the following morning about six o'clock ; he was obliged 
to have assistance in dressing himself, and experienced a numbness of 
his left, and afterwards of his right side. He attempted to walk, but 
could not without help, and it was observed that he dragged his feet. 
He sat down in a chair and almost instantly expired, at eight o'clock 
a.m., on the 12th of January, precisely five months from the receipt 
of the injury. 

"The autopsy was made thirty hours after death, by Dr. C. E. 
Isaacs, in presence of several medical gentlemen. Muscular develop- 
ment uncommonly fine. An unusual prominence discovered in the 
region of the axis and atlas. On making an incision from the occiput 
along the spines of the cervical vertebrae, the parts were found to be 
very vascular. These vertebra were removed en masse, and a careful 
examination instituted. The transverse, the odontoid (ligamenta mod- 
eratoria), as also all the ligaments of this region, excepting the occipito- 
axoideum, were in a state of perfect integrity; this latter was partially 
destroyed. A considerable amount of coagulated blood was found 
effused between the fractured surfaces, some of it apparently recent, but 
much of it was thought to have occurred at the 
FlG ' 42, time of the accident, and afterwards to have pre- 

vented the union of the bones. The spinal cord 
exhibited no appearances of any lesion. The 
odontoid process was found in the position well 
represented in the accompanying illustration, 
completely fractured off, and its lower extremity 
inclining backwards toward the cord. Death 
finally took place, doubtless, from the displace- 
ment of the process during some unfortunate 
movement of the head, by which pressure was 
made upon the cord. The destruction of the 
occipito-axoid ligament, which would otherwise 
have protected the contents of the spinal cavity, 
Fracture of the odontoid must have favored this result." 1 
process of the axis. Parker's j) r . Philip Bevan presented to the Surgical 

case. A. Broken surface. B. . , nr i i • i o/>r» • i, • j 

odontoid process. society of Ireland, m 1862, a specimen obtained 

from the dead-room, and which was supposed to 
be an epiphyseal separation of the odontoid process, occurring in early 
life. The history of the case is not known, although the woman was 
forty years old when she died. It does not appear very clear to us 
whether this was really an epiphyseal separation, or the result of some 
morbid process. 2 

1 Bigelow, New York Journ. Med., March, 1853, p. 164. 

2 Bevan, Araer. Journ. Med. Sci., April, 1864. From Dublin Med. Press, Feb. 
18, 1863. 




FRACTURES OF THE ATLAS. 167 

At the meeting of the New York Pathological Society, Nov. 12, 
1868, Dr. Austin Flint presented a case of separation of the odontoid 
process of the axis. 

Dr. W. Bayard, of St. John, N. B., has, however, reported a case of 
separation of the odontoid process in a child, followed by complete re- 
covery. In August, 1864, Charlotte Magee, of St. John, set. 6 years, 
previously in excellent health, fell five feet, striking on her head and 
neck, causing an immediate immobility of the head, which continued 
about two years and a half, when an abscess formed in the back of the 
pharynx, and the bone was spontaneously discharged. Since then she 
has been able to move the head freely, and her recovery may be said 
to be complete. 1 The specimen was subsequently presented to the 
New York Pathological Society, and no doubt remains that the entire 
process was thrown off. 

Dr. Stephen Smith, who has written a very instructive paper on this 
subject, has collected 23 cases of separation of the odontoid process, at 
least 20 of which must be regarded as fractures. The ages of the 
patients range from three years to sixty-eight. Eight of this number 
were spontaneous, the separation being apparently due to some progres- 
sive disease or atrophy of the bone. Two of these recovered after the 
formation of abscesses in the pharynx and the extrusion of the bone. 
In four cases the fractures were gunshot, and one died. The remainder, 
so far as ascertained, were in consequence of blows upon the head ; and 
of these only the girl Charlotte Magee recovered. Of the whole num- 
ber, 23, three were without history, two of them being dissecting-room 
cases. 2 

Symptoms. — These will depend much upon the cause and complica- 
tions of the accident. In all cases there will be more or less inability 
to support the head in the erect posture, and if displacement exists, or 
if the products of inflammation form upon the cord, a proportionate 
impairment of its functions must ensue. 

Treatment. — The treatment consists in absolute quietude, with mod- 
erate extension, effected by means of suitable apparatus. 

I 6. Fractures of the Atlas. 

I have been able to find only one example of a fracture of the atlas 
alone, and this is the case related by Sir Astley Cooper as having come 
under the observation of Mr. Cline. 

A boy, about three years old, injured his neck in a severe fall; in 
consequence of which he was obliged to walk carefully upright, as per- 
sons do when carrying a weight on the head ; and when he wished to 
examine any object beneath him, he supported his chin upon his hand, 
and gradually lowered his head, to enable him to direct his eyes down- 
wards. In the same manner, also, he supported his head from behind 
in looking upwards. Whenever he was suddenly shaken or jarred, the 
shock caused great pain, and he was obliged to support his chin with 
his hands, or to rest his elbows upon a table, and thus support his 

1 Bayard, Canada Med. Journ., Dec. 1869. 

2 Smith, Amer. Journ. Med. Sei., Oct. 1871, p. 338. 



168 FRACTURES OF THE VERTEBRAE. 

head. The boy lived in this condition about one year, and after death 
Mr. Cline made a dissection, and ascertained that the atlas was broken 
in such a manner that the odontoid process of the axis had lost its sup- 
port, and was constantly liable to fall back upon the spinal marrow. 1 

§ 7. Fractures of the first two Cervical Vertebras (Atlas and Axis) 
at the same time. 

A woman, set. 68, fell down a flight of steps, striking upon her fore- 
head, and died immediately. Upon making a dissection, it was found 
that the atlas was broken upon both sides near the transverse pro- 
cesses, and the odontoid process of the axis was broken at its base. 
These fractures were accompanied with a rupture of the atloido-odon- 
toid ligaments, and a dislocation of the atlas backwards. 2 

South says there is a specimen in the museum of St. Thomas's Hos- 
pital, showing this double fracture. The man had received his injury 
only a few hours before admission to the hospital, and died on the fifth 
day. On examination, the atlas was found to be broken in two places, 
and the odontoid process of the axis at its root. The fifth vertebra 
was also broken through its body. With neither fracture was there 
sufficient displacement to produce pressure, but a small quantity of ex- 
travasated blood lay in the substance of the spinal marrow, and its 
tissue was at one point broken down and disorganized. 3 

Mr. Phillips relates that a man fell from a hay-rick, striking upon 
the occiput; after which, although- momentarily stunned, he walked 
half a mile to the parish surgeon, and in two days more he returned to 
his occupation. About four weeks after the accident he was seen by 
Mr. Phillips, who discovered a small tumor over the second cervical 
vertebra, pressure upon which caused a slight pain. He complained 
also that his neck was stiff, and that he was unable to rotate it. No 
other disturbance of the functions of the body could be discovered. 
After a time the tonsils became swollen, and the patient experienced 
some difficulty in deglutition, and, upon examining the throat, a slight 
projection or fulness was discovered at the back of the larynx, opposite 
the second cervical vertebra. Subsequently he became affected with 
general anasarca and pleuritic effusions, of which he finally died. Up 
to the last week of his life he was able to walk about his bedroom, and 
his condition presented no other evidence than has been mentioned, 
that he was suffering from an injury of the spine. He died forty-seven 
weeks after the receipt of the injury. 

The autopsy disclosed a fracture with displacement of the atlas, and 
a fracture of the odontoid process of the axis. The two vertebrae were 
united to each other firmly by complete bony callus. 4 



1 Cline, Sir Astley Cooper, op. cit., p. 459. 

2 Malgaigne, op. cit., torn, ii, p. 333. 

3 Chelius's Surgery, note by South, vol. i, p. 588. 

4 Phillips, Med.-Chir. Trans , vol. xx, 1837, p. 384. 



FRACTURES OF THE STERNUM. 169 



CHAPTEE XVI. 

FKACTUEES OF THE STEKNUM. 

Fractures of the sternum are of rare occurrence, owing, probably, 
to the elasticity of the ribs and their cartilages, upon which it mainly 
rests, and also, in part, to the softness of its structure. In advanced 
life, the ossification and fusion of all of its several portions becoming 
more complete, and the cartilages of the ribs also becoming more or 
less ossified, its fracture is relatively more frequent. 

Causes. — They are generally the result of direct blows inflicted upon 
the part, such as the passage of a loaded vehicle across the chest, the 
fall of a tree or of some heavy timber upon the body ; the fracture imply- 
ing always that great force has been applied. 

Indirect blows and voluntary muscular action alone have been 
known also occasionally to produce this fracture. 

David, in his Memoire sur les Contrecoups, published as a prize essay 
by the Academy of Medicine, mentions the case of a mason, who, in 
falling from a great height, struck upon his back against a cross-bar 
which intercepted his fall, in consequence of which the abdominal and 
sterno-cleido-mastoidean muscles were so stretched that the sternum 
broke asunder between its upper and middle portions. 1 Sabatier re- 
ports another case of fracture at the same point, produced in a similar 
manner; 2 and Roland has described a third example in a woman 
sixty-three years old, who, falling from a height backwards and strik- 
ing upon her back, broke the sternum near its centre. 3 Gross has re- 
corded a similar case. 4 

Cruveilhier saw a man who, having fallen from a height of twenty 
feet upon his nates, was found to have a fracture of the sternum. 5 
Cussan saw the same result in a person who fell from a third story, 
striking first upon his feet and then pitching over upon his back. 6 
Maunoury and Thore have reported an analogous case, where a man 
fell from a height of twelve or fifteen metres, first striking upon his 
feet and then falling over upon his back and head. 7 

Mr. Johnson, late editor of the London Med.-Chir. Rev., reports a 
case as having been received into St. George's Hospital, in which the 
man, a healthy laborer from the country, had fallen from the top of a 
hay-cart, striking only upon his head. He walked with his head much 
bent forwards, and was incapable of either flexing, extending, or rotating 

1 Boyer on Bones, p. 57. 

2 Malgaigne, from Sabatier, Mem. sur la Fract. du Sternum. 

3 Ibid., from Bull, de Therap., torn, vi, p. 288. 

4 Gross, System of Surg., 5th ed., vol. i, p. 964. 

6 Malgaigne, from Bull, de la Soc. Anat., Juin, 1826. 

6 Ibid., from Archiv. de Med., Janv. 1827. 

7 Ibid., from Gaz. Med., 1842, p. 361. 

12 



170 



FRACTURES OF THE STERNUM. 



it any farther. The fracture was transverse, and about three inches 
below the top of the sternum, opposite the centre of the third rib, the 
lower fragment projecting in front of the upper. The fragments were 
easily replaced by simply throwing the head back, and fell into place 
with an audible snap, but immediately resumed their unnatural posi- 
tion when the head was flexed. They finally united, but with a slight 
projection and overlapping. 1 

Malgaigne expresses a doubt whether all these can be considered as 
the results of muscular action, since, in a certain number of the exam- 
ples cited, the head seems to have been thrown forwards by the con- 
cussion, and in others, also, there is no evidence that the muscles at- 
tached to the sternum were put upon the stretch. The only remaining 
explanation is that in such cases the sternum has been broken by the 
violent shock, or contrecoup. 

John T. Hodgen, of St. Louis, has reported to me one example of 
fracture of the sternum caused by a crushing force applied to the back, 
and in which, we may see plainly, that muscular action was not con- 
cerned. A man, seated upon a wagon, was driving under a low bridge 
with his head very much bent down. The bridge caught his back, 
opposite the shoulders and crushed him forwards, "separating the ver- 
tebrae in the dorsal region, and breaking the sternum about three inches 
below its upper end." This man recovered. 

Among the most authentic examples of fracture of this bone from 
muscular action alone are those in which it has occurred during labor. 
Malgaigne has collected three of these cases, and to these the American 
translator, Dr. Packard, has added two more, most of which took 
place at or near the junction of the first and second pieces of the ster- 
num. Lately Dr. Borland has added one more example, which took 
place at a point near the fourth costal cartilage. 2 

Malgaigne relates also the case of a mountebank, who, leaning back 

to lift with his feet and hands a 
weight, felt suddenly a severe 
pain in the sternal region, and 
fell over with a fracture of this 
bone. 

Seat and Direction of Frac- 
ture. — The sternum is separated 
most frequently either in the long 
central portion, or at the junc- 
tion of this with the upper por- 
tion, where the bone is weakest. 
In fact, a separation at this lat- 
ter point may be regarded fre- 
quently as a diastasis or dislo- 
cation rather than as a fracture, 
since the two portions do not 
become firmly united by bone 

Sternum, showing the periods at which its several . J . J 1 

parts unite by hone. (From Gray.) Until late in lite. Ihe Very late 



Fig. 4?. 





%^X!!/ 


J eoccep&tncZcCage 




W""' '" % 


Tim r 


!• z 


35 -/ r O. 
J Z0-25fhyear 


I 3 i 




I a 1 


\ soo7t after puherty 




Vp -a-.aJ 

\ s 1 




\6 \ 


■vftrtly cartiljtgirums in, 
advanced life 



1 London Med.-Chir. Rev., vol. xvii, new series, p. 536, 1832. 

2 J. N. Borland, M.D., Boston Med. and Surg. Jour., April 20, 1875. 



FRACTURES OF THE STERNUM. 171 

ossification and fusion of the xiphoid cartilage with the central piece, 
also, will explain the infrequency of its fracture. 

Boyer believed that the xiphoid cartilage was not susceptible of 
being permanently displaced backwards, except in aged persons, after 
it had become ossified, " for," he says, " though violently struck and 
driven backwards by a blow on what is vulgarly termed the pit of the 
stomach, yet it restores itself by its own elasticity." 1 

The following case, however, which has come under my own obser- 
vation, is conclusive as to the possibility of this accident : 

A man, twenty-eight years old, fell forwards, striking the lower end 
of his sternum upon the top of a candlestick, breaking in the xiphoid 
cartilage. During two years following the accident he had frequent 
attacks of vomiting, which were excessively violent and distressing ; 
the paroxysms occurring every five or six days. Both Dr. Green, of 
Albany, and Dr. White, of Cherry Valley, upon whom he called for 
relief, recommended excision of the cartilage, but the patient would 
not submit to the operation. Twelve years after the accident, in the 
year 1848, while he was an inmate of the Buffalo Hospital of the 
Sisters of Charity, I examined his chest, and found the xiphoid carti- 
lage bent at right angles with the sternum, pointing directly toward 
the spine. He now suffered no inconvenience from it, except that it 
hurt him occasionally when he coughed. 2 

The upper portion of the sternum is rarely broken, unless at the 
same time the central portion is broken also. 

The direction of these fractures is generally transverse, or nearly so ; 
occasionally a slight obliquity is found in the direction of the thick- 
ness of the bone. In three or four examples upon record, the direction 
of the fracture was longitudinal. It is not so un frequent, however, to 
find the bone comminuted. Compound fractures are exceedingly rare. 

When the fracture is transverse, the lower fragment is almost always 
displaced forwards, and sometimes it slightly overlaps the upper frag- 
ment. 

In one instance mentioned by Saba tier, where the separation had taken 
place at the point of junction between the first and second pieces, the lower 
fragment was displaced backwards, and was also carried upwards under 
the upper fragment to the extent of twenty-eight millimetres. 

I have seen a remarkable case of separation of the manubrium from 
the gladiolus, accompanied with a true fracture and other complications. 

Louis Wilson, set. 60, was admitted into the Long Island College 
Hospital, April 4, 1866, having just fallen through the hatchway of a 
vessel. He had a compound comminuted fracture of the right leg, a 
fracture of the four first ribs on each side at their necks, a dislocation 
of the sternum from the cartilages of both second ribs, a dislocation of 
the left third cartilage from its rib, a dislocation of the first from the 
second bone of the sternum, and a transverse fracture of the sternum 
three-quarters of an inch below the top of the gladiolus. The dislo- 
cation of the manubrium was complete, and it was thrust behind the 
upper end of the gladiolus, underlapping it half an inch. The trans- 

1 Boyer on Diseases of Bones, p. 59. 

2 Buffalo Med. Journ., vol. xii, p. '282, Cases of Fractures of the Sternum. 



172 FRACTURES OF THE STERNUM. 

verse fracture three-quarters of an inch lower down was also complete, 
and the fragment thus separated was divided into two, namely, an 
anterior and a posterior fragment, by a transverse splitting ; the ante- 
rior moiety retaining its attachment to the periosteum below, and not 
being displaced, while the posterior moiety retained its attachment to 
the periosteum both above and below, and was pushed downwards by 
the descent of the manubrium. His mind was clear, but he had 
paralysis of the bladder, and was breathing with some embarrassment. 
I had no difficulty in diagnosticating the dislocation of the third car- 
tilage, and of the manubrium. There was no swelling or discoloration 
on the front of the chest, but it was quite tender. His head was not 
thrown forwards. He complained of some soreness on the back of his 
head. His general condition was such that I did not attempt reduc- 
tion. The following day he expectorated blood, and on the third day 
he died. The autopsy revealed some effusions of blood underneath 
the pleura, but no lesions of the heart or lungs. The evidence is in 
this case conclusive that he struck upon his back and head, in fact, 
that it was a fracture from counter-stroke, by which the head, neck, 
and three or four upper vertebrae were bent forwards with great force, 
thus doubling forwards the top of the sternum. 

Dr. Robert Watts, Jr., of this city, has reported a very similar case, 
in which death occurred on the same day. The fragments of the 
sternum were not displaced, but the ribs had suffered similar lesions. 1 

Diagnosis. — In a few cases the patients have felt the bone break at 
the moment of the accident. When displacement exists, it may gene- 
rally be easily recognized, and the lower fragment will often be seen 
to move forwards and backwards at each inspiration and expiration. 
Crepitus may also be detected in some of these examples, but it is less 
often present where no displacement exists. To determine the exist- 
ence of crepitus, the hand should be placed over the supposed seat of 
fracture, while the patient is directed to make forced inspirations and 
expirations, or the ear may be applied directly to the chest. 

Emphysema has, also, occasionally been noticed, indicating usually 
that the lungs have been penetrated by the broken fragments. 

The frequent occurrence of congenital malformations of the sternum 
should warn us to exercise great care in our examinations, lest we mis- 
take these natural irregularities for fractures. Bransby Cooper men- 
tions a remarkable instance of malformation of the xiphoid cartilage 
which he at first suspected to be a fracture. It was so much curved 
backwards that, as Mr. Cooper thinks, its pressure upon the stomach 
produced a constant disposition to vomit whenever he had taken a full 
meal, or had taken a draught of water. 2 

Prognosis. — In simple fracture of this bone, uncomplicated with 
lesions of the subjacent viscera, and especially when the fracture is the 
result of muscular action or of a counter-stroke, no serious consequences 
are to be apprehended. The bone unites promptly even where it is 
found impossible to bring its broken edges into apposition. Indeed, 

1 Watts, Am. Med. Times, vol. iii, p. 55. 

2 B. Cooper, Princ. and Pract. of Surg., p. 359. 



FRACTURES OF THE STERNUM. 173 

generally, where the fragments have been once completely displaced, 
although it is not difficult to replace them momentarily, a redisplace- 
ment soon occurs, and they are found finally to have united by over- 
lapping; but no evil consequences usually result from this malposition. 
In nearly all of the cases reported in which palpitations, difficult 
breathing, etc., have been charged to the persistence of the displace- 
ment, the injuries were of such a character as to furnish for these un- 
fortunate results other and much more adequate explanations. In one 
instance only, already mentioned, serious inconveniences followed from 
a displacement of the cartilage backwards. 

In other cases, however, where the fracture is the result of a direct 
blow, constituting a large majority of the whole number, the prognosis 
is often very grave; a conclusion to which one would naturally arrive 
from the fact already stated, that the fracture of the sternum thus pro- 
duced, in itself implies the application of great force. 

An abscess occurring in the anterior mediastinum, and caries or ne- 
crosis of the bone, are among the most common results of a blow de- 
livered directly upon the sternum; complications which generally end 
sooner or later in death. Blood may be also extensively effused into 
the anterior mediastinum. 

A remarkable case of recovery after gunshot injury of the sternum 
is reported by the U. S. Medical Bureau: 

Private C. Betts, 26th N. J. Vols., set. 22, was struck by a three- 
ounce grapeshot, May 3, 1863, in the charge upon the heights at 
Fredericksburg, Va. The ball comminuted the sternum, opposite the 
third rib on the left side, penetrating the costal pleura. The patient 
removed the ball from the wound himself. On the following day he 
was admitted to the hospital of the second division of the sixth corps. 
Through the wound the arch of the aorta was distinctly visible, and its 
pulsations could be counted. The left lung was collapsed; when sit- 
ting up, there was but slight dyspnoea. Several fragments of the 
sternum Avere removed. The wound soon began to heal, and he made 
a complete recovery. 1 

Where emphysema is present, we may anticipate inflammation of the 
pleura and of the lungs. 

In several instances, where death has occurred speedily after the in- 
jury, the heart has been found penetrated and torn by the fragments. 
Sanson and Dupuytren have each reported one example of this kind. 
Duverney has mentioned two, and Samuel Cooper says there is a speci- 
men in the museum of the University College, exhibiting a laceration 
of the right ventricle of the heart by a portion of fractured sternum. 
Watson mentions a case in which the pericardium was torn but the 
heart was only contused. 2 

Treatment. — When the fragments are not displaced, the only indica- 
tions of treatment are to immobilize the chest, and to allay the inflam- 
mation, pain, etc., consequent upon the injury to the viscera of the chest. 
The first of these indications is accomplished, at least in some degree, 

1 Circular No. 6, Washington, D. C, Nov. 1, 1865, p. 23. 

2 New York Journ. Med., vol. iii, p. 351. 



174 FRACTURES OF THE STERNUM. 

by inclosing the body, from the armpits down to the margin of the 
floating ribs, with a broad cotton or flannel band. A single band, 
neatly and snugly secured, and made fast with pins, is preferable to, 
because it is more easily applied than, the roller which surgeons have 
generally employed ; it is also much less liable to become disarranged. 
It should be pinned while the patient is making a full expiration. To 
prevent its sliding down, two strips of bandage should be attached to 
its upper margin, and crossed over the shoulders in the form of sus- 
penders* 

Generally the patients prefer the half-sitting posture, with the head 
and shoulders thrown a little backwards; and this is the position which 
will be most likely to maintain the fragments in place, and also to secure 
immobility to the external thoracic muscles, while it leaves the dia- 
phragm and the abdominal muscles free to act. 

The second indication may demand the use of the lancet; but more 
often it will be found necessary to allay the pain and disposition to 
cough by the use of opium. 

If, however, the fragments are displaced,, it is proper first to attempt 
their reduction; which, as we have already intimated, is generally more 
easy of accomplishment than is the maintenance of them in place until 
a cure is effected. 

The upper fragment may be thrown forwards, and made to resume 
its position sometimes by a single full inspiration; but then it usually 
falls back during expiration; or it may be reduced by straightening the 
spine forcibly, and at the same time drawing the shoulders back. 

Verduc and Petit proposed in those cases in which it was found im- 
possible to reduce the fragments by these simple means, to cut down 
and lift the depressed bone. JSJelaton suggests the use of a blunt crotchet 
introduced through a narrow incision; and Malgaigne has thought 
of another plan, which is, to penetrate the skin with a punch, and di- 
recting it to the broken margin, to push the fragment into its place, 
but which he does not himself regard as a suggestion of much value, 
since the bone is too soft to aiford the necessary resistance; and, more- 
over, this, in common with all of the other similar methods, is liable, 
in some degree, to the objection that it may increase the tendency to 
caries and suppuration, already imminent. If reduced, the fragments 
will probably immediately again become displaced; and more than all, 
it still remains to be proven conclusively that the mere riding of the 
fragments is in itself ever a cause of subsequent suffering, or even of 
inconvenience. 

When an abscess has formed in the anterior mediastinum, surgeons 
have occasionally recommended the use of the trephine. Gibson has 
twice operated in this manner at the Philadelphia Hospital, but in 
each case the caries continued to extend, and the patient died ; an ex- 
perience which has inclined him latterly to discountenance the opera- 
tion. 1 

There are other consideratins mentioned by Lonsdale, which ought 
to decide us never to use the trephine in these cases. " For the symp- 

1 Gibson, Institutes and Practice of Surgery, vol. i, p. 269. 



FRACTURES OF THE RIBS. 175 

toms denoting the presence of the abscess, when completely confined 
to the under surface of the bone, will be very uncertain ; and when 
the matter collects in large quantities, it will show itself at the margin 
of the sternum, between the ribs, when it can be let out by making a 
puncture with the point of a lancet, without the necessity of removing 
a portion of the bone." x Ashhurst, referring to the same point, re- 
marks: "The fact that the mediastinal space can be cut into without 
injury to the pleura is shown by many cases, among others by one 
which came under my own observation." 2 

We have already said that a separation of the first from the second 
piece of the sternum, occurring before ossific union had taken place, 
might with some propriety be regarded as a diastasis, or as a dislo- 
cation even. Maisonneuve, Yidal (de Casis), Malgaigne, and other 
French surgeons speak of it as a dislocation, and Yidal has collected 
five examples, in all of which the lower bone occupied a position in 
front of the upper. Malgaigne enumerates ten examples. The points 
of difference between the dislocation and the true fracture are too 
small, however, to demand of us especial attention. 



CHAPTER XVII. 

FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

\ 1. Fractures of the Ribs. 

Fractures of the ribs, observed more often than fractures of the 
sternum, are rare as compared with fractures of other long bones. 

In my records, not including fractures from gunshot injuries, only 
twenty-five patients are reported as having had broken ribs ; but as 
in several of the cases two or more ribs were broken at the same time, 
the total number of fractures is about fifty-eight. If, however, I had 
always accepted the diagnosis made by other surgeons, the number 
would have been much greater, since I have been repeatedly assured 
that the ribs were broken when, upon the most careful examination, 
no evidence, beyond the existence of a severe pain and of difficult res- 
piration, has been presented to me. 

Etiology. — The force requisite to break the ribs is scarcely less than 
what is requisite to break the sternum ; and in childhood and infancy 
it is sometimes almost impossible to break them, so that children and 
even adults are often crushed and killed outright, where, although the 
pressure has been directly upon the thorax, the ribs have resumed their 
positions, and have been found not to be broken. I have met with 
several examples of this kind. 

In old age, the cartilages ossify and the ribs themselves suffer a 
gradual atrophy, w T hich renders them much more liable to break. 

The most common causes are direct blows, of very great force, in 

1 Lonsdale, Practical Treatise on Fractures, London, 1838, p. 242. 

2 Ashhurst, Am. Journ. Med. Sci., Jan. and Oct. 1862.. 



176 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

consequence of which sometimes the fragments are not only broken, 
but more or less forced inwards ; occasionally they ar,e the result of 
counter-strokes, and then the fragments, if they deviate at all from 
their natural position, are salient outwards; a species of fracture which 
I have not met with so often. 

Malgaigne has collected eight examples of fractures of the ribs pro- 
duced by muscular action, by the beating of the heart, etc., all of which 
occurred upon the left side. It is believed, however, that in all of 
these cases the ribs had previously become atrophied, and perhaps 
undergone other changes in their structure, rendering them liable to 
fracture from the action of trivial causes. 

Pathology, Seat, etc. — The fourth, fifth, sixth, and seventh ribs are 
most liable to be broken ; the upper ribs, and especially the first rib, 
being so well protected in various ways as to greatly diminish their 
liability, while the loose and floating condition of the last two ribs 
gives them an almost complete exemption. 

In my own cases I have found the first, second and third ribs each 
broken four times; the fourth, six times; the fifth, twelve times; the 
sixth, twelve times ; the seventh, nine times ; the eighth, ninth, and 
tenth, twice each. 

Twenty-one were broken through their anterior thirds, generally at 
or near the junction of the cartilages with the ribs; ten through their 
middle thirds ; and twenty through their posterior thirds. Malgaigne 
has noticed, also, contrary to the general opinion of surgeons, that the 
ribs are most often broken in their anterior thirds, whether the cause 
has been a direct or a counter blow. 

The direction of the fracture is generally transverse or slightly ob- 
lique; sometimes it is quite oblique. It is often compound; and in a 
few instances I have found it comminuted or multiple. Where the 
fracture is compound, it is rendered so generally by the fragments 
having penetrated the lungs, and not by a tegumentary wound. In 
only twelve of the twenty -five cases recorded by me, has the fracture 
been uncomplicated with fractures or dislocations of other bones. 

Displacement cannot occur in the direction of the axis of the bone 
unless several ribs are broken at the same time. The fragments are 
therefore either not at all displaced, or they fall inwards toward the 
cavity of the chest, or outwards, or very slightly downwards, in the di- 
rection of the intercostal spaces. Sometimes the rib moves a little upon 
its own axis. 

Prognosis. — Death occurs sooner or later in a pretty large minority 
of the cases in which the ribs have been broken ; yet not often as a 
direct consequence of the fracture, but only as. a result of the injury 
inflicted upon the viscera of the chest, or of other injuries received at 
the same moment. The violent compression of the heart and lungs 
has frequently produced death, and sometimes, as I have more than 
once seen, almost immediately; or the patients have succumbed at a 
later period to acute pneumonitis, or pleuritis. 

Lonsdale saw a case in which the body of a man having been trav- 
ersed by the wheel of a wagon, eight ribs were broken, and death 
having followed almost immediately, the autopsy disclosed a rent in 



FRACTURES OF THE RIBS. 



177 



the left auricle of the heart, produced by one of the broken ribs. 1 
South says there is such a specimen at St. Thomas's Hospital. 2 

Dupuytren reports a similar case. The same surgeon has also seen 
several deaths produced by the emphysema, independent of the fracture, 
two of which are particularly described in his Clinical Lectures. 3 
Amesbury has seen a case of death from rupture of the intercostal ar- 
tery, where there was no injury of the lungs. 4 

In several instances observed by me, patients have suffered from 
pains in the side, occasionally from cough, etc., after the lapse of two 
or more years, and I suspect it is no uncommon thing for these injuries 
to entail some such permanent disability, but which is a consequence 
rather of the injury to the viscera of the chest, than of any condition of 
the broken ribs themselves. 

In general, simple fractures of the ribs unite in from twenty-five to* 
thirty days. Malgaigne has seen one case of non-union; Huguier met 
with another upon the cadaver, in which a complete false joint existed, 
furnished with a capsule and lined with synovial membrane ; 5 Eve, of 
Nashville, Tenn., saw a case of non-union, occasioned, probably, by a 
caries or necrosis of the bone, since it was accompanied with a discharge 
of matter, and in which a removal of the ends of the fragments resulted 
promptly in a cure of the sinus; 6 and Samuel Cooper says there is a 
specimen in the Museum of the University College, of ar fracture of six 
ribs where the fragments are only connected by a fibrous or ligamentous 
tissue. 7 

The union generally occurs with only a slight degree of displace- 
ment. 

After the union is completed, even where there is no displacement, a 
certain amount of ensheathing callus may generally be felt at the point 
of fracture. Of five cases which I have carefully examined after re- 
covery, in only one instance was I unable to detect any irregularity at 
this point. I have in my cabinet nine specimens of fractured ribs, in 
four of which the en- 
sheathing callus is com- 
pletely formed, but the 
fragments are in perfect 
apposition : in one, ap- 
position is preserved , but 
there is no ensheathing 
callus ; and the remain- 
ing four, all occurring 
in the same person, are 
united with displace- 
ment, but without a pro- 
per ensheathing callus. 

In some specimens I 
have observed sharp spicule, in others broader sheets, of bone extend- 



Fig. 44. 




Fractured ribs joined to each other by osseous matter. (From 
Dr. Gross's cabinet.) 



1 Lonsdale on Fractures, p. 258. 2 Chelius's Surgery, by South, vol. i, p. 599. 
3 Dupuytren, op. cit., p. 79. 4 Amesbury on Fractures, vol. ii, 612. 

5 Malgaigne, op. cit., p. 435. 6 Eve, N. Y. Journ. Med., vol. xv, p. 136. 

7 S. Cooper's Surg., vol. ii, p. 321. 



178 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

ing along the course of the intercostal muscles from one rib to the 
other, forming a species of anchylosis between their adjacent margins. 

Symptomatology. — Acute pain, referred especially to the point of frac- 
ture, sometimes producing great embarrassment in the respiration, and 
crepitus, are the most common indications of a fracture. The pain and 
embarrassed respiration are, however, far from being diagnostic, since 
they are often present in an equal degree when the walls of the chest 
have only been severely contused. 

The crepitus, also, is often difficult to detect, owing to the thickness 
of the muscular coverings, or to the amount of fat upon the body, or to 
the fracture having occurred perhaps directly underneath the mamma? 
in the female. In three instances, where the presence of emphysema 
rendered the existence of a fracture quite certain, I have been unable 
immediately after the accident to discover crepitus. 

The crepitus may be discovered sometimes by pressing gently upon 
the seat of fracture, or by applying the ear or the stethoscope over this 
point while the patient attempts a full inspiration, or coughs ; or we 
may press upon the front of the chest with one hand, while the fingers 
of the other hand rest upon the fracture. 

Occasionally the patient has felt the bone break, and very often he 
feels or hears the crepitus after it is broken, and will himself indicate 
very clearly the point of fracture. 

At the same time that we detect crepitus we are able also to discover 
motion in the fragments, but I have once or twice discovered preter- 
natural mobility without crepitus. 

Emphysema, which is almost certainly indicative of a fracture, is 
present in a pretty large proportion of cases. It has been observed by 
me in eleven out of twenty-five cases ; generally it did not extend over 
more than two or three square feet of surface ; but in two cases it finally 
extended over nearly the whole body. It is remarkable, however, that 
in only four of these eleven cases did the patients expectorate blood, 
and then in a very small quantity, and usually not until the second or 
third day. 

Desault observes that emphysema rarely succeeds to fractures of the 
ribs ; an observation which, as will be seen, my experience does not 
confirm. 

Treatment. — In simple fractures, where there is no displacement, or 
where the displacement is only moderate, the chest may be inclosed 
with a broad belt or band, as we have already directed in case of frac- 
ture of the sternum ; provided always that it is not found to increase 
instead of diminishing the patient's sufferings. Some patients cannot 
tolerate this confinement at all ; while with a majority, although it is 
at first uncomfortable and oppressive, after an hour or two it affords 
great relief from the distressing pain, and they will not consent to have 
it removed even for a moment. In nearly all cases of comminuted 
fracture it is inadmissible, on account of its tendency to force the pieces 
inwards. 

Hannay, of England, has suggested the use of adhesive strips as a 
substitute for the cotton or flannel band ; the several successive pieces 



FRACTURES OF THE RIBS. 179 

being imbricated upon each other until the whole chest is covered. 1 
The same objection holds to this mode of dressing as to a similar mode 
of dressing a broken clavicle, which has been recently recommended. 
It will certainly become loosened after a few hours, by the slight but 
uninterrupted play of the ribs. 

The forearm ought also to be brought across the chest at a right 
angle with the arm, and secured in this position with a moderately 
tight bandage or sling, so as to prevent any motion in the pectoral 
muscles. 

As to position, the patient generally prefers to sit up, or he chooses 
a position only partly reclining upon his back ; but there is no positive 
rule to be observed in this matter, except that such a position shall 
be chosen as shall prove most comfortable to the patient. 

If the fragments are salient outwards, the fracture having been pro- 
duced by a counter-stroke, they may be reduced by pressing gently 
upon them from without. If, on the contrary, the fragments are salient 
inwards, they will be found, in a great majority of cases, to have re- 
sumed their positions spontaneously or through the natural actions of 
respiration ; but if they have not, it will be exceedingly difficult to re- 
store them. Possibly it may be accomplished by pressing forcibly 
upon the front of the chest, or upon the anterior extremity of the 
broken rib ; yet if the fragments are comminuted, and the ends are 
much driven in, this method will avail little or nothing. In such cases 
several surgeons have recommended that we should cut down to the 
bone and elevate the fragments, but Rossi alone claims to have actually 
put the suggestion into practice. 

No doubt, if the necessity was urgent, this method might be success- 
fully adopted; or, instead of cutting down to the broken rib, we might 
even seize the fragment with a hook, as suggested by Malgaigne, or 
what in some cases might be even more convenient, with a pair of for- 
ceps constructed with long teeth, obliquely set upon a firm shaft. Yet 
the exigency which will demand a resort to any of these measures will 
be exceedingly rare. In gunshot fractures, which are nearly all com- 
pound and comminuted, the loosened or detached fragments should be 
at once removed. 

In no case do I attach any value or importance to the advice given 
by Petit, that we shall place a compress upon the front of the chest, 
underneath the bandage, in order to reduce the fragments, or to retain 
them in place after reduction. Lisfranc, who advocated this method, 
claimed that its advantage consisted in the increased length which was 
thus given to the antero-posterior diameter of the chest, and the conse- 
quent accumulation of pressure from the encircling band, in this direc- 
tion. 2 The mechanical law is no doubt correctly stated, but its value 
in practice is too inconsiderable to deserve consideration. 

The emphysema generally demands no especial attention, since it is 

1 American Journ Med. iSei., vol. xxxix, p. 198. From Lond. Med. G-az., Nov. 
1845. 

2 Ranking's Abstract, vol. ii, p. 204, from Gaz. des Hopitaux, July 8, 1845. 



180 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

usually too limited to occasion inconvenience ; and when more exten- 
sive, it generally disappears spontaneously after a few days, or a few 
weeks at most. The advice given by some surgeons, that we ought 
in these cases to cut down to the pleural cavity so as to allow the air 
to escape freely through the incision, seems thus far to have rested its 
reputation upon a more than doubtful theory rather than upon any 
testimony of experience. Abernethy alone, so far as I know, has actu- 
ally made the experiment, and his patient died. 

Dupuytren, in the two cases already alluded to, bled the patients 
and applied resolvent liquids, with rollers ; he also made incisions with 
the lancet at various points of the body, more or less remote from the 
seat of fracture, a practice, however, in which he confesses he has no 
confidence whatever. These patients both died. 

Dr. Stedman, of the Massachusetts General Hospital, has reported the 
case of a man aged sixty -nine, of intemperate habits, who, in addition 
to a fracture of one of his ribs, had also a dislocation of the outer end of 
the clavicle. The emphysema commenced immediately, and reached 
its acme on the twenty-second day. At this time it had extended over 
his whole body ; his eyes were closed, and he breathed with great diffi- 
culty; but on the forty-fifth day the emphysema had entirely disap- 
peared, and he was dismissed cured. The treatment consisted chiefly 
in the free internal use of stimulants, and in the application of band- 
ages ; but the bandages soon became disarranged, and after a few days 
they were entirely laid aside. 1 

In the case of one of my own patients, where the emphysema was 
almost equally extensive, the patient recovered after a few weeks, under 
the use of a simple diet, and without any special medication whatever. 
The second case of extensive emphysema, observed by me, was as fol- 
lows : A man was crushed, under a bank of earth, Sept. 19, 1860. 
Two hours after the accident I found him greatly prostrated. Six ribs 
were broken on the left side near the spine, and one on the right side. 
In coughing he expectorated some blood. There was emphysema of 
the face and over the front of the chest. He died at 9 p.m., having 
survived the accident only about six hours. The autopsy showed the 
left lung penetrated at two points, and collapsed ; about six ounces of 
blood in the left pleural cavity ; lower lobe of right lung crushed and 
disorganized, but the remainder of the lung not collapsed. The fea- 
tures of the face were almost obliterated by the emphysema, which had 
also invaded the mediastinal space, and extended over the body as low 
as the knees. 

I 2. Fractures of the Cartilages of the Ribs. 

Boyer was incorrect when be said that the cartilages of the ribs 
could not be broken until they were ossified. They are often broken 
when there is no ossification, at the same time that the ribs themselves 
are broken. Sometimes they are broken alone. Not unfrequently, 

1 Boston Med. and Surg. Journ., vol. lii, p. 316. 



FEACTUEES OF THE CARTILAGES OF THE RIBS. 181 

also, the separation takes place at the precise point of junction between 
the cartilage and the bone. 

Pyper relates a case in which the sternum was broken in a man aged 
twenty-five years, and also the cartilages of the sixth, seventh, and 
eighth ribs of the right side, as was proven by the autopsy, yet the 
cartilages were not ossified. The vena cava ascendens was also rup- 
tured by the force of the compression. 1 The reader is referred also to 
my own and Dr. Watts's cases reported in the chapter on Fractures of 
the Sternum. Since the date of the report of these cases I have met 
with several examples of fracture of the cartilages. 

Etiology. — The causes are the same as those which produce fractures 
of the ribs, yet it is generally understood that it will require greater 
force, and that consequently the injury done to the viscera of the 
thorax will be more complicated and intense. 

In the reports of the Massachusetts General Hospital an account is 
given of the case of a man aged thirty, who was crushed by the fall of 
a heavy weight upon his body, and who died after about sixty hours. 
An examination after death revealed a fracture of the cartilages of the 
third and fourth ribs, with a laceration of the intercostal muscles to 
such an extent that a hernia of the lungs had occurred at this point. 
This hernia had been discovered and recognized by Dr. Warren soon 
after the accident occurred ; the protrusion being at that time as large 
as the clenched fist, and regularly rising and falling with each move- 
ment of respiration. It was accompanied, also, with a moderate em- 
physema. 

Pathology. — The fracture is clean and vertical, or transverse ; never 
irregular or oblique. The direction of the displacement varies as in 
fractures of the ribs, but the anterior or sternal fragment is generally 
found in front of the posterior or spinal. 

Union takes place in these fractures, not through the medium of 
cartilage, but of bone. Sometimes the new bone being deposited only 
between the ends of the fragments, in the form of a thin plate, and at 
other times it is formed around the fragments as well as between them. 
The latter of these two processes has been most frequently observed. 
The eusheathing callus appears to be supplied by the perichondrium, 
while the experiments of Dr. Redfern render it probable that the in- 
termediate callus may result from a conversion or transformation of 
the adjacent cartilaginous surfaces. Paget remarks, also, that the ossi- 
fication extends to the parts of the cartilage immediately adjacent to 
the fracture. 

I have seen one example, in the person of Hiram Leech, set. 38, 
which, after the expiration of more than one year, had not united. 
The fracture had occurred in the united cartilages of the tenth and 
eleventh ribs. The posterior fragment overlapped the anterior, and 
they played freely upon each other at each act of inspiration and ex- 
piration. 

I do not know that any observations have been made upon the repair 
of these cartilages in very early life, and it is possible that the process 

1 Banking's Abstract, vol. i, p. 147, from the Lancet, Oct. 1844. 



182 FRACTURES OF THE CLAVICLE. 

may differ from this, which has been described as it has been observed 
in the adult. 

Ti^eatment. — The treatment need not differ from that already recom- 
mended for fractured ribs. 



CHAPTER XVIII. 

FRACTURES OF THE CLAVICLE. 

For the sake of convenience, I shall divide fractures of the clavicle 
into those occurring through the inner, middle, and outer thirds. By 
the " outer third " is meant all that portion of the clavicle included 
between its scapular extremity and the internal margin of the conoid 
ligament. The remaining portion is intended to be divided equally 
into two separate thirds. The peculiarities of these several portions, 
in respect to anatomical relations, liability to fracture, results, etc., will 
explain the propriety of the divisions. 

Causes. — If we except gunshot fractures, the clavicle is broken, in 
a large majority of cases, by a counter-stroke, such as a fall, or a blow 
upon the extremity of the shoulder. 

Occasionally it is broken by a direct stroke, as when a blow aimed 
at the head is received upon the shoulder; it is broken sometimes by 
the recoil of an overloaded gun, especially when the person lies upon 
the ground, with the butt of the gun resting against the clavicle. 

Gibson has seen a case in which it was broken in a child at birth, 
by an ignorant midwife pulling at the arm, 1 and Dr. Atkinson has 
reported an example of intra-uterine fracture of the clavicle. 2 

Gurlt has collected seven cases of intra-uterine fracture of the clav- 
icle caused by external violence. 3 

I have once seen the clavicle broken by muscular action alone. A 
large, well-built, and healthy man, aged thirty-seven, standing upon 
the ground, attempted to secure the braces of his carriage-top with his 
right arm, when he felt a sudden snap, as if something about his shoulder 
had given way. He did not, however, suspect the nature of the injury, 
and did not consult any surgeon until eight days after, at which time 
I found the right clavicle broken near its centre, but rather nearer the 
sternal than the scapular extremity. The fragments were but slightly, if 
at all, displaced, but motion and crepitus at the point of fracture were 
distinct. The usual node-like swelling was also present, indicating the 
existence of a considerable amount of ensheathing callus. He had been 
unable to raise the arm to a right angle with the body since it was- 
broken, but he had suffered no other inconvenience from it. 

A similar case is reported in the number for January, 1843, of the 

1 Gibson, Principles of Surg., sixth ed., vol. i, p. 272. 

2 Atkinson, Bost. Med. and Surg. Journ., July 26, 1860. 
8 Gurlt, Holmes's Surgery, ed. of 1870, vol. ii^ p. 765. 



FRACTURES OF THE CLAVICLE. 183 

American Journal of Medical Sciences, copied from the Revista Medica. 
The subject of this case was a colonel of cavalry, about sixty years of 
age. In mounting his horse, he experienced a sensation as if something 
had broken, followed by acute pain in his left shoulder, and, on exam- 
ination, it was found that the clavicle was fractured in the middle. 
The health of this gentleman had been impaired, it is further stated, 
by repeated attacks of syphilis. 

W. E. Whitehead, U. S. N., has reported the case of a healthy and 
muscular man, twenty-eight years old, who broke his left clavicle at 
the junction of the outer and middle thirds, while attempting to raise 
himself to a platform eight feet high. The fracture was transverse, 
and unaccompanied with displacement. 1 

Malgaigne has recorded three other examples of fracture of this bone 
from muscular action ; and Parker saw a case which was produced by 
striking at a dog with a whip. The bone, in the latter case, had been 
previously somewhat diseased, yet it united favorably. 2 

Of these seven cases, five occurred on the right side, and always near 
the middle of the bone, if we except one case reported by Malgaigne, 
in which the point of fracture is not mentioned. In neither case did 
the fragments become displaced, only as they were found, in some of 
the examples, inclined slightly forwards. 

Gurlt has collected twenty cases of fracture from this cause. 3 

Pathology. — It has already been observed, in speaking of partial 
fractures, that this bone suffers an incomplete fracture more often than 
any other, and that in such cases the lesion occurs generally in the 
middle third, or rather to the sternal side of the centre, and in a direc- 
tion nearly or quite transverse. They are not usually accompanied 
with much displacement ; but if a displacement exists, it is a slight 
forward inclination of the fragments. 

Fractures which are complete occur mostly after the bones have 
become firm and unyielding. They are also generally oblique, seldom 
comminuted, still more rarely compound. The point of the clavicle 
at which a complete fracture usually occurs is at or near the outer end 
of the middle third, and a little to the sternal side of the coraco-clav- 
icular ligaments, near where the trapezius and deltoid cease their at- 
tachments. It might be more exact to say that the fracture extends 
from this point downwards and inwards, toward the sternum, embrac- 
ing one inch or less of its entire length. In some cases the obliquity 
is greater, and the amount of bone involved is much more considerable. 

Why the bone should break more frequently at this point, especially 
in the adult and in the male, it is not difficult to understand. It is 
smaller here than elsewhere, and less supported by muscular and liga- 
mentous attachments. At this point, also, the axis of the bone begins 
pretty abruptly to curve forwards, and more abruptly in the adult and 
male than in the child and female. When, therefore, the clavicle is 
broken, as it usually is, by a counter-stroke, the force of the blow, 

1 Whitehead, Pacific Med. and Surg. Journ., 1871. 

2 Parker, N. Y. Journ. Med., July, 1852 

3 Gurlt, Holmes's Surgery, ed. of 1870, vol. ii, p. 765. 



184 



FRACTURES OF THE CLAVICLE. 



Fig. 45. 




conveyed from the shoulder through the outer portion of the bone, is 
suddenly arrested, and expends itself upon the point where the direc- 
tion of the axis is changed. 

In a record of one hundred and forty-two fractures, including partial 
and comminuted, and not including gunshot fractures, one hundred 

and twelve have occurred through 
the middle third; and, with the ex- 
ception of the partial fractures, the 
fracture has in nearly all of the cases 
taken place near the outer end of this 
third. Four have occurred through 
the inner third, three of which were 
within one inch of the sternum ; and 
seventeen through the outer third. 

A more practical analysis can be 
based, however, upon the point of 
fracture with reference to its cause; 
and I have never, but once, seen a 
complete fracture of this bone pro- 
duced clearly by a counter-stroke, 
which was not near the outer end of 
the middle third. 

When the fracture is at this point, 
or in any portion of the middle third, 
the direction of the displacement is 
almost uniformly the same. The sternal fragment is slightly lifted by 
the action of the clavicular portion of the sterno-cleido-mastoid muscle, 
notwithstanding the resistance of the rhomboid ligament, and the sub- 
clavian muscle. On the other hand, the acromial fragment is dragged 
downwards by the weight of the arm, aided by the conjoined action of 
a portion of the pectoralis major and the latissimus dorsi, feebly resisted 
by the trapezius and other muscles from above ; by the action of the 
same muscles, aided by the pectoralis minor, and perhaps by some 
portion of the subclavius, it is drawn toward the body, diminishing 
thereby the axillary space ; while by the preponderating strength of 
the pectoralis major and minor, the acromial end of the fragment, with 
the shoulder, is drawn forwards; the sternal end of the same fragment 
being rather displaced backwards, and at the same time resting at a 
point somewhat elevated above the acromial end. 

Desault has recorded one example of an overlapping by the eleva- 
tion of the acromial fragment over the sternal ; T and Bichat remarks 
that Hippocrates speaks of the phenomenon as a thing which was 
familiar to him. Syme has mentioned a case of this kind which he 
had seen. 2 Gueretin, Malgaigne, 3 and Stephen Smith have each re- 
ported an example. 4 In Stephen Smith's case the fracture occurred in 
a man thirty-eight years old. The bone was broken through the outer 
third, and transversely. He was treated at the Bellevue Hospital, but 



Complete oblique fracture of clavicle. 



1 Desault on Frac, op. cit., p. 16. 2 Amer. Journ. Med. Sci., vol. xvii, p. 251. 
3 Malgaigne, p. 4G1. 4 N. Y. Jour, of Med., May, 1857. 



FRACTURES OF THE CLAVICLE. 185 

the overlapping, to the extent of one inch, remained after the cure was 
completed. 

Margaret O'Donnell, set. 40, was admitted to the Charity Hospital, 
Blackwell's Island, June 1, 1868, with a single fracture of the clavi- 
cle, near its middle, caused two weeks before, by a fall on the shoulder. 
The sternal fragment was lying beneath the acromial, and in this posi- 
tion it finally united. 

In nearly all the cases of oblique fractures occurring through the 
middle third there follows immediately an overlapping, varying from 
one-quarter of an inch to an inch, and sometimes, though very rarely, 
exceeding this. There is a specimen in the Dupuytren Museum, in 
which the shortening equals one-third of its entire length. 

Transverse fractures, wherever they may occur, are seldom found 
displaced, at least in the direction of the axis of the bone, as the fol- 
lowing examples will illustrate : 

An old lady, aged eighty years, fell down a flight of stairs, breaking 
the right clavicle transversely, about one inch from the sternum. I 
saw her, with Dr. Trowbridge, on the day following the accident. 
Motion and crepitus were distinct, but there was scarcely any displace- 
ment. No dressings were applied, but she was directed to keep quiet 
in bed, and upon her back. In the usual time the fragments had 
united, without deformity. 

A man, about forty years old, fell backwards from a wagon, break- 
ing the collar-bone near the middle. The fragments were movable, 
tut not displaced. He was treated successfully and without any result- 
ing deformity, by simple confinement in the recumbent posture during 
a few days, and after this by suspending the arm in a sling, while he 
was permitted to walk about. 

A young man, aged twenty-six, fell while wrestling and broke the 
clavicle at the outer end of the middle third. There was some dis- 
placement at first, but the fragments being reduced, were found to 
support themselves. A cross, secured with straps, was applied to the 
back, and on the twenty-eighth day the union was complete, and with- 
out deformity. 

A child, aged three years, fell about six feet, striking upon liis 
shoulder. He was sent to me on the same day, by Dr. G, JBurwell. I 
found the left clavicle broken off completely, about one inch from its 
scapular end. Crepitus and motion were distinct, but the fragments 
were not displaced. The arm was placed in a sling, and on the seventh 
day both motion and crepitus had ceased. The cure was accomplished 
without any degree of displacement. 

The example of a fracture from muscular action, already mentioned 
as having been seen by me, was also probably transverse, and union 
has occurred without treatment and without displacement. 

Stephen Smith, of New York, has met with two examples of trans- 
verse fractures without displacement, in a hospital record of eleven 
cases. Bichat says Desault has frequently observed the same, it having 
been seen three times at Hotel Dieu, in the course of the year 1787. 1 

1 Desault on Fractures, op. cit., p. 15 
13 



186 FRACTURES OF THE CLAVICLE. 

Desault thinks, also, that sometimes the fracture, taking place obliquely 
upwards and inwards, the usual form of displacement is prevented, and 
apposition is preserved. In nearly all of the examples of partial 
transverse fractures, occurring in children, seen by me, there has been 
no longitudinal displacement. 

If the fracture is near the sternum, and within the fibres of the 
costo-clavicular ligaments, as in the case of the old lady just cited, the 
displacement is inconsiderable. I have seen one other similar case, in 
an adult also. Lonsdale mentions a case, in a child three years old, 
which came under his observation in Middlesex Hospital, 1 which he 
regarded as a separation of the epiphysis, the point of fracture being 
half an inch from the sternum ; but the only epiphysis in connection 
with this bone, is an exceedingly thin plate at the sternal end, which 
does not begin to ossify until about the eighteenth year of life. Neither 
the age of the patient, nor the point of separation, would justify an 
opinion that this was an epiphyseal separation. Malgaigne mentions 
two other examples, in one of which the fracture was so near the ster- 
num that it was difficult to say whether it was not a partial dislocation. 
The displacement was only trivial. 2 But the only two specimens con- 
tained in the Dupuytren Museum offer a considerable displacement, 
and in both the external fragment is thrown downwards and forwards. 

March 22, 1865, I presented to the New York Pathological Society 
a similar case, obtained from a patient in Bellevue Hospital. The 
man from whom this specimen was taken was forty-five years old, and 
the fracture, occasioned by a fall upon the shoulder, extended from the 
sterno-clavicular articulation upwards and outwards one inch and a 
half. The fragments were overlapped three-quarters of an inch, and 
were firmly united. The character of the accident was not recognized 
until after death. The specimen is now in the museum of the Belle- 
vue Hopital. 

With regard to the amount of displacement usually attendant upon 
fractures near the outer end of the bone, surgical writers have generally 
united in declaring that it was in a majority of cases very inconsidera- 
ble, while some have even affirmed that there would be found no dis- 
placement whatever ; neither of which opinions, according to the ob- 
servations of Robert Smith, of Dublin, is strictly correct. He has 
examined eight specimens of fracture of the outer extremity of the clav- 
icle, contained in the museum of the Richmond Hospital School of 
Medicine; three of which were broken between the conoid and trape- 
zoid ligaments, and are united with very little displacement, while the 
remaining five, broken beyond the trapezoid ligament, present a very 
marked deformity. 

The following is a summary of the conclusions to which he has 
arrived : 

" When the clavicle is broken between the two fasciculi of the coraco- 
clavicular ligament, there is seldom any displacement of either frag- 
ment, and always much less than in fracture of any other portion of 

1 Lonsdale on Fractures, p. 206. 2 Malgaigne, op. cit., p. 491. 




FRACTURES OF THE CLAVICLE. 187 

the bone. When displacement does occur, it is usually limited to a 
slight alteration in the direction of the bone, by which the natural con- 
vexity of this portion of the clavicle is increased. 

" The explanation of which facts is found in the attachments of the 
ligaments from below to the two fragments; and in the action of the 
trapezius from above, by which they are antagonized. 

" But the case is very different when the bone is broken external to 
the trapezoid ligament. Here the coraco-clavicular ligaments can have 
no direct influence upon the outer fragment, which is displaced now 
partly by muscular action, and partly by the weight 
of the arm, the sternal end of the outer fragment 
being drawn upwards by the clavicular portion of 
the trapezius, while, by the action of the muscles 
passing from the chest, the entire outer fragment 
is drawn forwards and inwards, so as to bring 
sometimes its broken surface into contact with the _ t ._ ,. 

„ „ , „ it- Fracture outside of trape- 

antenor surface of the inner fragment, and placing zoid ligament. United. 
it nearly at right angles with this fragment, in 

which position it is generally united. The displacement in this direc- 
tion, rather than any degree of overlapping, explains also the shorten- 
ing which existed in all of these cases, varying in the different specimens 
from half an inch to one inch, and averaging about three-quarters of an 
inch." 

Such are the views of Mr. Smith, and I see no reason to call in 
question their correctness. In my own experience, a fracture occurring 
in a child three years old, within one inch of the acromial end, proba- 
bly between the ligaments, was never displaced at all ; a second, and 
third, occurring in adults, presented no displacement. Two cases were 
displaced each one-quarter of an inch, and two cases, half an inch ; 
these four latter cases occurred in adults, and always within an inch of 
the acromial end of the bone. In one of these last examples, the inner 
fragment was rather behind than above the outer fragment. 

But it would be unsafe to draw conclusions from an experience which 
is confined entirely to living examples, and in which no dissections 
have been made, to verify the exact point of fracture, or the precise 
amount and character of the displacement. So far as they go, however, 
they seem to me to confirm the general correctness of the observations 
made by Robert Smith. 

It has happened to me only six times to meet with a comminuted 
fracture of the clavicle, except in cases of gunshot injuries, all of which 
fractures occurred through some portion of the middle third of the 
bone ; the intercepted fragments being from one inch to one inch and a 
half in length, and lying obliquely, or, as in one case observed by me,, 
at nearly a right angle with the main fragments. 

I have never seen a compound fracture of this bone except as the 
result of a gunshot injury, although, in many cases, the sharp point of 
an oblique fracture has seemed just ready to penetrate the skin. 

One case is reported as having been presented at St. Bartholomew's 
Hospital. It occurred in a boy fourteen years old, and was produced 



188 



FRACTURES OF THE CLAVICLE. 



Fig. 47. 



by his having been drawn into some machinery while it was in motion. 1 
Two similar cases are reported from the New York Hospital, as having 
been observed during the last ten years. The whole number of exam- 
ples of fracture of the clavicle during this period was 191. 2 

Lente also mentions a case, seen by himself, occasioned by the fall 
of a derrick upon the shoulder. The patient, twenty -four years old, 
was admitted into the New York Hospital in August, 1848. The left 
clavicle was broken at about its middle, and a large wound in the 
integuments communicated with the fracture. The fragments united 
firmly in about six weeks, after several pieces of bone had been dis- 
charged from the wound. 3 

A double fracture, or a simultaneous fracture occurring in both clavi- 
cles, seldom occurs. I have recorded two cases (four fractures, three 
of which are incomplete), both occurring in young boys. 4 

Malgaigne says it has only happened to him to see it once in 2358 
cases, at the Hotel Dieu, and he can recollect only five other examples. 
And of 158 cases of broken clavicles reported from the New York 
Hospital, it is stated to have occurred in only four. These gentlemen 

however, only report hospital 
cases, and they have reference, 
doubtless, to complete fractures ; 
w T hile double fractures, accord- 
ing to my experience, occur more 
often in children than in adults, 
and are of the character of partial 
fractures, without usually much 
displacement; which facts, if sus- 
tained by subsequent observa- 
tions, would sufficiently explain 
their infrequency in hospital, and 
their relative frequency in private 
experience. 

Symptoms. — In all cases of 
complete fracture with displace- 
ment, no difficulty will be expe- 
rienced in deciding upon the 
nature of the injury. 

The patient is found generally 
leaning toward the injured side, 
while the opposite hand sustains the elbow of the same side, to prevent 
its dragging downwards. 

The shoulder falls downwards, forwards, and inwards; while, at the 
same time, the line of the bone is interrupted by the sharp and project- 
ing point of the sternal fragment. 

If the fracture is the result of a direct blow, a swelling and discolor- 




Complete Fracture. — Oblique; at junction of outer 
aud middle thirds. (From nature.) 



1 London Med. Gaz., vol. ii, p. 382. 

2 New York Med. Times, March 16, 1861. 

3 L.-nte, N. Y. Journ. of Med., July, 1850. 

4 Kep on Def. after Frac , Cases 5, 6, 10. 



FRACTURES OF THE CLAVICLE. 189 

ation may be seen at the seat of fracture; but if it is the result of a 
counter-stroke, we must look to the top or point of the shoulder for 
the signs of a contusion. 

The patient also experiences pain when an attempt is made to raise 
the arm at a right angle with the body, and especially in attempting 
to carry the arm across the body, by which the ends of the broken 
clavicle are driven into the flesh. In two cases (Cases 19 and 50 of 
my Report on Deformities) of oblique fracture, accompanied with dis- 
placement, occurring in the middle third of the bone, I have particu- 
larly noticed that the patients could easily lift the hands to the head, 
and in one of these cases the patient, a boy fourteen years old, raised 
his arm perpendicularly over his head. Such exceptions are not very 
uncommon. 

Crepitus can be detected sometimes by simply pressing down the 
sternal fragments, but it is almost always present when we draw the 
shoulders forcibly back, so as to bring the broken fragments into more 
perfect contact. 

If there is no displacement, still crepitus may generally be discovered 
by grasping the bone between the thumb and fingers, and moving it 
gently up and down, or by slight pressure upon the point of fracture. 

When the fracture occurs close to the acromial extremity, external 
to the coraco-clavicular ligaments, quite frequently there is no percep- 
tible or marked displacement, and its diagnosis will require, therefore, 
more care and attention on the part of the surgeon. 

Prognosis in this fracture deserves especial attention. In no other 
bone, except the femur, does a shortening so uniformly result. Of 
seventy-two complete fractures only sixteen united without shortening ; 
and of twenty-seven simple, oblique, complete fractures, which occurred 
at or near the outer end of the middle third, only one united without 
shortening (Case 46 of my Report), and in this case the patient was 
but fifteen years old, and the fragments were never much displaced ; 
nor can I say that the treatment — a board across the back, after the 
manner of Keckerley — had anything to do with the result. Six cases 
of complete transverse fracture, occurring at the same point, united 
without shortening. 

The shortening, after the union is consummated, varies from one- 
quarter of an inch to one inch or more; and the fragments are almost 
always, especially when the fracture is through the middle third, found 
lying in the position in which we have described them to be at the first : 
the outer end of the inner fragment being above, and often a little 
in front of, the. outer ; sometimes, especially in lean persons, and when 
the fractures are very oblique, presenting a sharp and unseemly pro- 
jection. 

The greatest amount of shortening is generally found in those frac- 
tures which occur through the middle third ; in fractures near the 
sternal end there is usually very little permanent displacement ; the 
same is true when the fracture is at the acromial end, and between 
the coraco-clavicular ligaments, as the observations of Robert Smith, 
already quoted, have sufficiently established ; but if the fracture is 



190 



FRACTURES OF THE CLAVICLE. 



beyond these ligaments, the final displacement and deformity may be 
very great. 

The presence of a small amount of ensheathing callus soon after the 
cure is completed, sometimes increases the deformity. It is rarely 
seen to encircle the bone completely, and occasionaly it appears to 
be most abundant in the direction of the salient points of the fracture, 
that is, above and below ; so that, unless the examination is made with 
care, the projecting points of callus which remain, sometimes after 
many years, may be easily mistaken for an intercepted fragment turned 
at right angles to the axis of the bone. 

Robert Smith has observed, also, that in cases of fracture external 
to the conoid ligament, osseous matter is freely formed upon the under 
surface of each fragment, but there is seldom any deposited upon the 
upper surface of either. These osseous growths, occupying the situ- 
ation of the co raco -clavicular ligaments, frequently prolong themselves 
as far as the coracoid process, and in some cases to the notch of the 
scapula. Still less frequently these osteophytes become fused with the 
coracoid process, and a true anchylosis exists. 

In comminuted fractures the intercepted fragments generally fall off 
from the line of the other fragments, and cannot easily be restored. 

The clavicle being a spongy and vascular bone, usually unites with 
great rapidity, generally within twenty days. In the fourth example 

of transverse fracture already men- 
tioned as having been seen by me, 
the union seemed to be tolerably 
firm in seven days. Wallace reports 
one case from the Pennsylvania 
Hospital, which was cured in eight 
days, and another in nine days. 1 
Yelpeau says the clavicle will unite 
in from fifteen to twenty-five days; 
Benjamin Bell, in fourteen; Stephen 
Smith has seen it firm in fifteen 
days. 

Whatever may be the degree of 
displacement, or the condition of 
the system, unless in a case of gun- 
shot fracture, it is very seldom that 
it refuses to unite altogether, or 
that the union is ligamentous ; and 
in the few cases found upon record 
of a ligamentous union, the func- 
tions of the arm do not seem to have suffered any serious ultimate 
injury, as the following example will illustrate: 

Edmund Nugent, a stout Irish laborer, twenty-five years old, was 
received into the Buffalo Hospital of the Sisters of Charity, in March, 
1854. Several years before, he fell from a horse and broke his left 
clavicle, at the outer end of the middle third. This was near Cork, 




Comminuted Fracture. — United. 
(From nature.) 



Am. Journ. Med. Sci., vol. xvi, p. 115. 



FRACTURES OF THE CLAVICLE. 191 

in Ireland ; and, without consulting any surgeon or " handy man," he 
continued at work, holding the tail of the plough, nor from that day 
forward did he employ a surgeon, or dress his arm, or cease from his 
work. 

The clavicle presented the same deformity which many other simi- 
lar fractures present after what is usually termed successful treatment, 
except that it is not united by bone. The outer end of the inner frag- 
ment rode upon the inner end of the outer fragment half an inch. The 
ligament uniting the two extremities was so long and firm that it could 
be distinctly felt, and the fragments moved upon each other with great 
freedom. 

In order that we might determine the amount of injury which he 
had suffered from the ligamentous union, we directed him to lift 
weights placed on a table before him, while he was seated upon a chair. 
We ascertained from this experiment that with his left arm he could 
lift as much, within three ounces, as he could with his right, and he 
was not himself conscious of any difference. The muscles of the left 
arm seemed as well developed as those of the right. 

In May, 1868, I found in the Charity Hospital, Blackwell's Island, 
in the person of A. Bragg, set. 34, a fracture of the left clavicle, which 
had united only by ligament. The fracture had occurred, when he was 
twenty years old, at about the junction of the outer fourth with the 
inner three-fourths. No surgeon was employed, and no treatment had 
ever been adopted. The ligament was quite long, and the fragments 
moved freely upon each other, yet the arm was nearly as strong and as 
useful as before. 

Chelius also refers to two cases mentioned by Gurdy and Yelpeau, 
in'which, although an artificial joint remained, the use of the limb was 
but little impaired. 1 

In a case of compound and comminuted gunshot fracture reported 
by Ayres, of New York, the recovery was remarkable. The man was 
sixty -two years old, and in excellent health, when the injury was re- 
ceived. The clavicle was so extensively comminuted that before the 
wound closed over one-third of the bone had escaped, and yet at the end 
of one year from the time of the accident the shoulder was perfectly 
symmetrical with its fellow, without drooping or falling forwards. Dr. 
Ayres thinks that all of the clavicle which was lost had been reproduced. 

A partial paralysis, with atrophy of the muscles of the arm, accom- 
panied, also, with more or less rigidity and contraction of the muscles 
both of the arm and forearm, is, according to my observation, a more 
frequent result of these fractures. 

Mr. Earle has recorded a case of com minuted fracture of the clavicle, 
in which the nerves converging to form the axillary plexus were so 
much injured that paralysis of the arm ensued ; and it was noticed as 
an interesting fact, that the patient could not afterwards put her hand 
into even moderately warm water without the effects of a scald being 
produced, characterized by vesications, redness, etc. 2 

1 Chelius, Amer. ed., vol. i, p. 603. 

2 S. Cooper's First Lines, fourth Amer. ed., vol. ii, p. 323. 



li)2 FRACTURES OF THE CLAVICLE. 

Desault saw a case at Hotel Dieu, in which, although the clavicle 
was not broken, the force of the blow upon the clavicle was sufficient 
to produce a severe concussion of the brachial plexus, and paralysis 
of the arm. A timber had fallen from a building, striking upon the 
external part of the left clavicle. A considerable wound, followed by 
swelling, pointed out the place on which the blow had been received. 
No apparatus was applied, and on the third day a numbness and par- 
tial loss of the power of motion occurred in the arm of the affected side. 
Soon afterward an insensibility came on, and by the seventh day the 
paralysis of the arm was complete. It was not until after a tedious 
treatment that the limb recovered in part its original strength. 1 

In Case 23 of my report to the American Medical Association, which 
was followed by paralysis of the opposite arm, and spinal curvature, 
these results were probably due to some injury of the back received at 
the time of the accident; but one cannot avoid a suspicion that the 
apparatus, Brasdor's jacket, contributed somewhat to the unfortunate 
result. No axillary pad was employed, but the straps over each 
shoulder were buckled so tight that he was compelled to incline his 
head constantly to the right side. He was unable to lie down, and 
could only incline in a half-sitting posture. This treatment was con- 
tinued four weeks ; and two months after its removal the paralysis and 
spinal distortion commenced. 

In Case 38, also, of the same report, a comminuted fracture, paralysis 
with contraction of the muscles extending to the wrist and fingers ex- 
isted, but whether t was due to the severity of the original injury or 
to the treatment, could not be satisfactorily ascertained. 

Gibson relates a remarkable instance of this kind. A young man 
was struck on the clavicle by the falling limb of a tree, breaking it into 
numerous pieces, and bruising the parts so severely as to give rise to 
violent inflammation. "The fragments had been driven behind and 
beneath the level of the first rib, and so compressed the plexus of 
nerves as to wedge them into each other, and by the subsequent in- 
flammation to blend them inseparably together. Complete paralysis 
and atrophy of the whole arm ensued, and the patient's object in visit- 
ing Philadelphia was to submit to an operation, in hopes of elevating 
the clavicle to its natural height, and taking off pressure from the 
nerves." Dr. Gibson, however, did not believe that the prospect of 
success was sufficient to warrant the operation, and the young man was 
sent home. 2 

It will not do to deny, therefore, the possibility of a paralysis as re- 
sulting from a concussion of the axillary nerves, produced by a blow 
upon the clavicle, nor of a paralysis resulting from a direct injury in- 
flicted by the points of the fragments upon this plexus in certain very 
badly comminuted fractures; but it is certain that these conditions 
will not satisfactorily explain all of the examples in which paralysis 
has followed simple fractures. In some cases it is no doubt due rather 
to the injudicious mode of using an axillary pad, by means of which 



1 Desault on Frac. and Disloc, Amer. ed., p. 14, 1805. 

2 Gibson, op. cit., 6th ed., vol. i, p. 271. 



FRACTURES OF THE CLAVICLE. 



193 



the arm is converted into a powerful lever, and thus the brachial 
nerves are made to suffer from compression along the inner side of the 
arm itself. In short, it must be confessed that it is sometimes due to 
the treatment alone, and not to the original injury. 

•Parker, of New York, in a note to the edition of S. Cooper's Sur- 
gery, just quoted, declares that he has seen one patient who had lost 
the use of his arm from the pressure upon the nerves by the wedge- 
shaped pad, over which the limb was confined, in order to pry the 
shoulder outwards. Stephen Smith mentions a case of partial paralysis 
from the same cause. 1 

A similar case has come under my own observation. A lady, aged 
fifty-one years, was thrown from her carriage, breaking the right clav- 
icle obliquely at the outer end of the middle third. During the first 
three weeks the arm was dressed with Fox's apparatus, which was at 
no time particularly painful. She was then placed under the care of 
another surgeon, who, finding the fragments overlapped, applied very 
firmly a figure-of-8 bandage, with an axillary pad, securing the arm 
snugly to the side of the body ; hoping by these means to restore the 
fragments to their place. The pain which followed w r as excessive, and, 
notwithstanding the free use of anodynes, it became so insupportable 
that at the end of fourteen hours the dressings were removed by another 
surgeon, and Fox's apparatus again substituted. These were also ap- 
plied much more tightly than at first, and during the four weeks longer 
that they remained on, repeated attempts 
were made to reduce the fragments. 

Forty-eight days after the accident, 
she consulted me. The clavicle was then 
united, and overlapped half an inch. 
The whole arm was swollen, painful, 
and very tender, with total inability to 
move it. 

I removed all the dressings, and, 
during the time she remained under my 
care, in a private room at the hospital, 
there was a gradual improvement in the 
condition of her arm, in respect to swell- 
ing and tenderness, but the paralysis did 
not much abate. 

Erichsen thinks he has seen one case 
of comminuted fracture, produced by a 
direct blow, in which the subclavin artery 
w T as ruptured; great extravasation of 
blood resulted, and the arm was threat- 
ened with gangrene. The patient having 

j i .1 j« • in Velpeau's dextrin bandage : no axil- 

reCOVered, however, the diagnosis could larypad. 

not be determined by actual dissection. 2 

Since among surgeons some difference of opinion seems to exist as to 



Fig. 49. 




1 New York Journ. of Medicine, May, 1857. 

2 Erichsen, Surgery, Amer. ed , p. 205. 



194 FRACTURES OF THE CLAVICLE. 

the practicability of overcoming the displacement in certain fractures 
of the clavicle, it is proper that I should defend the accuracy of my 
own observations by a reference to the observations of others. 

In nine of eleven cases reported by Stephen Smith, one of the surgeons 
at Bellevue Hospital, New York, more or less deformity remained after 
the cure was completed. In the two remaining cases the actual results 
are unknown. 1 

Chelius remarks : "Setting of this fracture is easy, yet only in very 
rare cases is the cure possible without any deformity." .... "It is 
considered, also, that the close union of the fracture of the collar-bone 
depends less on the apparatus than on the position and direction of the 
fracture (therefore, in spite of the most careful application of this appa- 
ratus, some deformity often remains)." 2 

Velpeau, in a lecture given in 1846, and published in the Gazette 
des Ilopitaux, declares that with all the bandages imaginable, in the 
case of an oblique fracture at the junction of the outer third with the 
inner two-thirds, we cannot prevent deformity. 

Vidal observes : " Fracture of the clavicle is almost always followed 
by deformity, whatever may be the perfection of the apparatus and the 
care of the surgeon." 3 

"Hippocrates has observed that some degree of deformity almost 
always accompanies the reunion of a fractured clavicle; all writers 
since his time have made the same remark ; experience has confirmed 
the truth of it." 4 

Turner remarks as follows: "As to the reduction of this fracture, it 
must be owned the same is often easier replaced than retained in its 
place after it is reduced; for its office being principally to keep the 
head of the scapula, or shoulder, to which, at one end, it is articulate, 
from approaching too near, or falling in upon the sternum, or breast- 
bone, it happens that, on every motion of the arm, unless great care 
be taken, the clavicle therewith rising and sinking, the fractured parts 
are apt to be distorted thereby. Besides, even in the common respira- 
tion, the costse and sternum aforesaid, where the other end of this bone 
is adnected, together with the motion of the diaphragm, rising and fall- 
ing, especially if the same be extraordinary, as in coughing and sneez- 
ing, are able to undo your work, not to mention the situation thereof, 
less capable of being so well secured by bandage as many others. All 
which, duly considered, it is no wonder that upon many of these acci- 
dents, although great care has been taken, these bones are sometimes 
found to ride, and a protuberance is left behind, to the great regret 
particularly of the female sex, whose necks lie more exposed, and where 
no small grace or comeliness is usually placed." 5 

Says Johannis de Gorter : " Restituiter facile tractis humeris a min- 

1 New York Journ. Med., May, 1857, p. 382. 

2 System of Surgery. By J. M. Chelius, of Heidelberg, with notes by South. 
First Amer. ed., vol. i, pp. '603, 605. 

3 Vidal (de Cassis), Paris ed., vol. ii, p. 105. 

4 Treatise on Fractures and Luxations. By J. P. Desault. Edited by Xav. 
Bicbat, and translated by Charles Caldwell, M.D. Philadelphia, 1805, p. 9. 

5 The Art of Surgery, by Daniel Turner, vol. ii, p. 256. London ed., 1742. 



FRACTURES OF THE CLAVICLE. 195 

istro posterius, dum simul suo genu locato ad spinara dorsi, dorsum 
sustentet minister, nam tunc chirurgus folis digitis claviculam fractam 
reponere potest. Difficilius autem in reposita sede retinetur, sed loca 
cava supra et infra claviculam spleniis irnplenda." l 

Says Heister, writing only a little later : " The reduction of a broken 
clavicle is not very hard to be effected, especially when the fracture is 
transverse; nor is it unusual for the humerus, with the fragment of the 
clavicle, to be so far distorted as not to be easily replaced with the 
fingers ; but the difficulty is much greater to keep the bone in its place 
when the fracture is once reduced, especially if the bone was broken ob- 
liquely." 2 

Amesbury, after having exposed the inefficacy of all previous modes 
of dressing, and especially of the figure-of-8 bandage, Desault's, Boy- 
ers, and an apparatus recommended by Sir Astley Cooper, proceeds to 
describe his own apparatus and to affirm its excellence. It is, how- 
ever, not much unlike a multitude of others, and is liable to the same 
objections. 3 

M. Mayor, of Lausanne, thinks that up to this day no successful 
mode of treatment has been devised. "Here everything appears as 
yet so little determined, that each day sees some new propositions and 
different procedures," etc. He believes, however, that in his simple 
handkerchief bandage, with straps across each shoulder, the indica- 
tions are most fully accomplished and the most successful results are 
obtained. If, however, it were to be treated without apparatus, the 
horizontal position, lying upon the back, would, in the end, make the 
most perfect unions. 4 

Says M. Malgaigne: a The prognosis, considering the trivial charac- 
ter of this fracture, is sufficiently difficult. For, little as may be the 
displacement, the surgeon ought not to promise a reunion without de- 
formity; and certain successful results, proclaimed from time to time, 
betray, on the part of those who relate them, the most extravagant 
exaggerations." 5 

M. Nelaton having spoken of the various plans which have been 
suggested to retain this bone in place, and of their inefficiency, comes 
at last to speak of the handkerchief bandage of M. Mayor, and re- 
marks : 

" This apparel is very simple ; but neither will it remedy the over- 
lapping." . . . . " Of all the apparels which we have passed in review, 
there is, then, not one which fills completely the three indications usu- 
ally present in the fracture of a clavicle. None of them oppose the 
displacement ; they have no effect, with whatever care they may be 
applied, but to maintain immobility in the limb. "We think, then, 
that it is useless to fatigue the patient with an apparatus annoying, 

1 Johannis de Gorter ; Chirurgia Repurgata, p. 79. Lugduni Batavorum, 1742. 

2 Heister's Surgery, vol i, p. 134. London ed., 1768. 

3 Treatment of Fractures, by Joseph Amesbury, vol. ii, p 527. London ed., 1831. 

4 Nouveau Systeme de Delation Chirurgicale, par Mathias Mayor, de Lausanne, 
p 384, etc. (also Atlas, plate 3, figure 23). Paris ed., 1838. 

6 Traite des Fractures et des Luxations, par J. F. Malgaigne, tome premier, p. 
473. Paris ed., 1847. 



196 FRACTURES OF THE CLAVICLE. 

and, perhaps, even painful ; a simple sling, secured upon the sound 
shoulder, will be sufficiently severe. Nevertheless, as this does not 
assure so complete immobility as the bandage of M. Mayor, it is to 
this that we think the preference ought to be given in all cases of frac- 
tures of the clavicle, whether accompanied with displacement or not, 
whether they occupy the middle or the external part of the clavicle. 
If the fracture presents no displacement, we shall obtain a cure which 
will leave nothing to be desired. If there is a tendency to displace- 
ment, the consolidation will be effected with a deformity more or less 
marked ; but since this deformity is inevitable, at least with adults, 
whatever may be the apparel which we employ, it is evident that the 
apparatus which causes the least constraint ought to have the prefer- 
ence. We may remark, farther, that this union with deformity in no 
wise impairs the free exercise of all the movements of the members." 1 

"The venerable gentleman who stands at the head of American 
surgery, and whose manipulations with the roller approach very nearly 
to the limits of perfection, informed us, in 1824, that he had never 
seen a case of fractured clavicle cured by any apparatus, without ob- 
vious deformity." 2 

I need not say that the " venerable gentleman " to whom Dr. Coates 
refers in this passage was the late Dr. Physick, of Philadelphia. 

Dr. Gross says that, according to his experience, " fractures of the 
clavicle are seldom cured without more or less deformity, whatever 
pains may be taken to prevent it." 3 

Among the late German authors Roser speaks as follows : " The 
treatment of fractures of the clavicle is, after all that has been said, 
very imperfect ; and it is very often the case that, after a most careful 
treatment, some deformity will remain, such as protrusion of the inner 
fragment, crossing of the fragments, and consequent shortening." 4 

Says Bryant, in his excellent Treatise on Surgery : " Deformity 
almost always exists in spite of treatment," 5 

Treatment. — If evidence were needed beyond that which has been 
furnished, of the difficulty of bringing to a successful issue the treat- 
ment of this fracture, it might be supplied, one would think, by a 
reference merely to the immense number of contrivances which have 
been at one time and another recommended. 

A catalogue of the names only of the men who have, upon this 
single point, exercised their ingenuity, would be formidable, nor would 
it present any mean array of talent and of practical skill. 

All these surgeons, however, have admitted the same indications of 
treatment, viz., that in order to a complete restoration of the outer 
fragment, which alone is supposed to be much displaced, we are to 



1 Elements de Pathologie Chirurgicale, par A. Nelaton, tome premier, p. 720. 
Pari? ed., 1844. 

2 Keynell Coates, Amer. Med. Journ., vol. xviii, p. 62, old series. It is probable 
that Dr. Physick here referred to complete and oblique fractures of the middle 
third, or that Dr. Coates has forgotten the precise language employed on this occa- 
sion. 

3 Gross, System of Surgery, vol. i, p. 954, 1872. 

4 W. Roser, Handbuch der Anatomischen Chirurgie, 6 Aufl., Tubingen, 1872. 
6 Bryant, Practice of Surgery, 1872, p 927. 



FRACTURES OF THE CLAVICLE. 197 

carry the shoulder upwards, outwards, and backwards. But as to the 
means by which these indications can be most easily, if at all, accom- 
plished, the widest differences of opinion have prevailed ; and, in the 
debate, it may be seen that while, on the one hand, no invention has 
wanted for both advocates and admirers, on the other hand, no method 
has escaped its equivalent of censure. 

Hippocrates, Celsus, Dupuytren, Flaubert, Lizars, Pelletan, and 
others, directed the patients to lie upon their backs, with little or no 
apparatus. S. Cooper and Dorsey also recommend that the patients 
should be confined in this position during most of the treatment; and 
from the account given by Dr. Lente, it will be understood that a 
similar plan was at one time adopted in the New York City Hospital. 
" But this result (deformity) rarely happens when the patient has 
strictly followed the directions of the surgeon, as to position especially, 
for it is by position, more than by any other remedial means, that a 
good result is to be effected." 

Nearly the same method we find recommended by Alfred Post, in 
1840, then one of the surgeons of that hospital ; the arm being merely 
kept in a sling and bound to the side, with the patient lying upon his 
back. Dr. Post mentions a case treated in this manner, which termi- 
nated with very little deformity ; l and I have myself treated many 
cases by this plan, with more than average success. 

Recently, Dr. Edward Hartshorne, of Philadelphia, has published, 
in the second volume of the Pennsylvania Hospital Reports, 1869, a 
very ingenious argument in favor of the supine position, in which he 
seems to have demonstrated that the special efficacy of this plan de- 
pends upon the pressure made upon the angle of the scapula. In 
order to accomplish this, and to place the scapula in the position most 
favorable for the reduction of the clavicle, the back should rest upon 
a broad, firm, and unyielding mattress, and not upon a pillow between 
the shoulders, which latter has the effect rather to defeat than to pro- 
mote the indication ; the head should be slightly raised so as to relax 
the sterno-cleido-mastoid muscles and somewhat extend the trapezius ; 
the arm and forearm of the injured side should be flexed, resting across 
the chest, with the hand reaching over the sound shoulder, as recom- 
mended by Velpeau in the use of his dextrin apparatus, or it should 
be placed at right angles with the body, as recommended by Dupuy- 
tren. Bryant, of London, recommends essentially the same method. 

It is scarcely necessary to say that the absolute immobility required 
by the posture treatment must always limit its application, and render 
its general employment impossible. Dr. J. A. Packard, of Philadel- 
phia, regards the scapula, also, as the bone upon which the restoration 
of the clavicle chiefly depends ; and he finds in the serratus magnus the 
especial obstacle to this restoration. 2 

Dr. Eve, of Nashville, Tenn., and Dr. Eastman, of Broome County, 
N. Y., have also employed this method successfully; 3 while Malgaigne 
declares it to be the most reliable means of obtaining an exact union. 

1 N. Y. Journ. of Med , vol. ii, p. 226. 

2 Packard, New York Journ. of Med., 1867. 

3 JBost. Med. and Surg. Journ., vol. lvi, p. 468. 



198 



FRACTURES OF THE CLAVICLE. 



Fig. 50. 




Figure-of-8. 



Albueasis, Lanfranc, Guy de Chauliac, Petit, Parr, Syme, Skey, 
Brunninghausen, and very many others, especially among the English, 

have preferred, in order to carry the 
shoulders back, a figure-of-8 ; while 
Desault, Colles, South, Bryant, and 
Samuel Cooper have represented this 
bandage as useless, annoying, and 
mischievous. 

Heister, Chelius, Miller, Breffield, 
Keckerly, 1 Coleman, 2 Hunton, 3 prefer, 
for this purpose, some form of back- 
splint, extending from acromion to 
acromion, against which the shoulders 
may be properly secured. Parker says 
that splints of this kind, with a figure- 
of-8 bandage, are " better than all the 
apparatus ever invented," while Mr. 
South gives his testimony in relation 
to all dressings of this sort as follows : 
" I do not like any of the apparatus 
in which the shoulders are drawn back 
by bandages, as these invariably annoy the patient, often cause excori- 
ation, and are never kept long in place, the person continually wrig- 
gling them off to relieve himself of the pressure." 

Fox, 4 Brown, 5 Desault, and others bring the elbow a little forwards, 
and then lift the shoulder upwards and backwards. Wattman and 
Lonsdale carry the elbow still farther forwards, so as to lay the hand 
across the opposite shoulder ; while Guillou carries the hand and fore- 
arm behind the patient, and then proceeds to lift the shoulder to its 
place. Moore, also, recommends that the elbow shall be carried back. 
Thus Desault, Fox, and Wattman accomplish the indication to carry 
the shoulder back, by lifting the humerus, with the elbow in front of 
the body ; while Guillou and Moore accomplish the same indication 
by lifting the humerus when the elbow is a little behind the body. 
Chelius also says : " The elbow, as far as possible, is to be laid back- 
wards on the body." 

Sargent, who believes that with Fox's apparatus " the occurrence of 
deformity is the exception," and not the rule, and prefers it to all 
others, has treated three cases by Guillou's method, and is perfectly 
satisfied with its operation. Hoi lings worth, of Philadelphia, has also 
treated one case successfully by Guillou's method, and adds his testi- 
mony in its favor. Several surgeons think they have obtained equal 
success with Moore's apparatus. 



1 Keckerly, Amer. Journ. Med. Sci., vol. xv, p. 115; also, my Report on Defor- 
mities after Fractures, in Trans, of Amer. Med. Assoc , vol viii, p. 440. 

2 Coleman, New York Journ. Med., second series, vol. iii, p. 274, from New 
Jersey Med. Rep. 

3 Hunton, ibid. ; also, New Jersey Med. Rep., vol. v, p. 146. 

4 Fox, Liston's Practical Surgery, Amer. ed., p 47. 

5 Brown, Sargent's Minor Surgery, p. 132. 



FRACTURES OF THE CLAVICLE. 199 

But how shall we explain these equal results from opposite modes 
of treatment? Is the indication to carry the shoulders back, which 
Fox sought to accomplish by pressing the elbow upwards and back- 
wards, as easily attained by pressing the elbow upwards and forwards? 
Or are we not compelled to infer that there has been some mistake as 
to the precise amount of good accomplished by the apparatus in either 
case ? Moreover, Coates, 1 Keal, and others instruct us that the only 
safe and proper position for the humerus is in a line with the side 
of the body, and that it must neither be carried forwards nor back- 
wards. 

Paulus iEgineta, Boyer, Desault, Pecceti, Liston, Fergusson, Samuel 
Cooper, Erichsen, Miller, Skey, Levis, Dorsey, 2 Gibson, 3 Fox, H. 
H. Smith, 4 Norris, 5 Sargent, Eastman, 6 recommend an axillary pad ; 
while Richeraud, Velpeau, Dupuytren, Benjamin Bell, Syme, Moore, 
deny its utility, or affirm its danger. Dr. Parker has seen one patient 
in whom paralysis of the arm resulted from the pressure upon the 
brachial nerves, in the attempt " to pry the shoulder out;" and I have 
myself recorded another. 

Cabot, of Boston, Massacusetts, has recommended a mould of gatta 
percha laid over the front and top of the chest. 7 

Desault's plan, which took its origin as Velpeau thinks, in the spica 
of Glaucius, under various modifications, is recommended by Delpech, 
Cruveilhier, Lasere, Flamant, Samuel Cooper, Fergusson, Liston, 
Cutler, Physick, Dorsey r Coates, and Gibson ; while by Velpeau, 
Syme, Colles, Chelius,. Samuel Cooper, and Parker it is regarded as 
inefficient and troublesome. Says Mr. Cooper : " In this country, 
many surgeons prefer Desault's bandages ; but I do not regard them 
as meeting the indications, and consider them worse than useless." 

The dextrin bandages, or apparatus immobile, of Blandin, Velpeau, 
and others, constitute only another form of the bandage dressing of 
Desault. In this connection it ought to be noticed that Velpeau does 
not regard the employment of this apparatus, or of any other demand- 
ing great restraint, as imperative. In his great work on anatomy, 
referring to the fact that when the bone is broken and overlapped, the 
patient is still able, in many cases,, to move the arm freely, he remarks : 
"Do not these cases give support to the opinion of those who admit 
that fractures of the clavicle do not actually require any other appa- 
ratus than the simple supporting bandage?" " It is necessary to ob- 
serve," he adds, " that by thus acting we do not prevent an overlap- 
ping," 8 etc. 

According to Flower and Hu]ke r authors of the article on "Injuries 

1 Coates, Amor. Journ. Med. Sci., vol. xviii, p. 62. 

2 D<>rsey, Elements of Surgery, vol. i, p. 153. 

3 Gibson, Institutes and Practice of Surgery, vol. i, p. 271. 

4 H. H. Smith, Practice of Surgery, p 354. 

5 Norris, Liston's Practical Surg.,. Amer ed., p. 46. 

6 Eastman, Apparatus for Fractured Clavicle, by Paul Eastman, Aurora, 111. j 
Boston Med. and Surg. Journ., vol. xxiii, p. 17^. 

7 Cabot, Bost Med. and Surg. Journ., vol Hi, p. 232. 

8 Velpeau, Anatomy, Amer. ed., vol. i, p. 242. 



200 



FRACTURES OF THE CLAVICLE. 



of the Upper Extremities" in the last edition of Holmes's Surgery, in 
most of the hospitals in London the surgeons employ a moderate-sized 
pad in the axilla, and then secure the arm to the body with a broad 
calico roller, some of the turns of which are made to pass beneath the 
elbow and over the opposite shoulder. Some of the surgeons advance 
the elbow, others carry it back, but a majority permit it to hang per- 
pendicularly beside the body. As will be hereafter seen, this plan is 
essentially the same as that adopted by myself. 

Professor E. M. Moore, of Rochester, in a paper read before the 

New York State Medical 
fig. 51. Society, in 1871, has called 

attention to what he terms 
the " Figure-of-8 from the 
elbow," by which he pro- 
poses to render tense the 
clavicular fibres of the pec- 
toral is major, and at the 
same time draw the scap- 
ula backwards toward the 
spine. He is thus able, he 
affirms, to overcome the 
action of the stern o-cleido- 
mastoid, which lifts the 
sternal fragment; and to 
draw the acromial frag- 
ment outwards and up- 
wards. 

These ends are accom- 
plished by placing the ex- 
tremity of the middle finger 
of the broken arm upon 
the ensiform cartilage, with the forearm and elbow pinned back and 
against the body. In order to secure the arm in this position, "I use," 
says Dr. Moore, "a shawl or piece of cotton cloth, which, when folded 
like a cravat, eight inches in breadth at the centre, should be about two 
yards long. Placing this at the centre across the palm of the surgeon, 
he seizes with this hand the elbow of the patient, which corresponds 
with the broken clavicle. The two ends of the bandage hang to the 
floor. The one falling inward toward the patient is carried upward, in 
front of the shoulder and over the back, making a spiral movement in 
front of the shoulder. This is intrusted to an assistant. The outer 
end is then carried across the forearm, behind the back, over the oppo- 
site shoulder, and around the axilla. This meets the other end, which 
may be carried under the axilla and over the shoulder of the opposite 
side, thus making the figure eight (8) turn, around the sound shoulder. 
This twist, it will be seen, makes also the figure eight (8) turn, around 
the elbow of the affected side. I therefore style the bandage, ' The 
elbow figure eight (8). ; " 

" The forearm should be sustained by a sling which raises it to an 




Moore's apparatus. Back view. 



FRACTURES OF THE CLAVICLE. 



201 




acute angle in order that gravity may assist in moving the whole arm 
backward. This is best 
done by a simple strip 
three or four inches wide, 
which may be pinned to 
the shawl at the shoulder, 
or by a sling across the 
opposite shoulder and be- 
hind the back. The for- 
mer much to be preferred. 
Any tendency on the part 
of the shawl to slide from 
the shoulder may be ar- 
rested by a pin thrust at 
the crossing. The shawl 
at the elbow is kept in 
place by folding the upper 
part that fits the arm and 
securing it by a pin. This 
makes a sort of cup for 
the elbow." 

The principle upon 
which this dressing is con- 
structed, appears to me sound ; but hitherto, in the five or six cases in 
which it has been employed under my observation it has failed to ac- 
complish any more than is accom- 
plished by many other forms of dress- 
ing. It is especially liable to become 
disarranged, and to cause excoriations 
in the sound axilla; in this respect 
being quite as obnoxious to criticism 
as the ordinary figure of eight. 

Dr. Lewis A. Sayre, of this city, 
has for some time employed an appa- 
ratus for dressing broken clavicles, by 
which he proposes, also, to render tense 
the clavicular attachments of the pec- 
toralis major, and thus secure more 
effectually the depression of the sternal 
fragment, while at the same time the 
shoulder is lifted and carried back. 

Two strips of adhesive plaster are 
prepared, each about three and a half 
inches wide, for an adult ; one long 
enough to encircle, first the arm, and 
then the body completely; the other 
of sufficient length to reach from the 
sound shoulder, over the point of the elbow of the broken limb, and 
across the back obliquely to the point of starting. Maw's moleskin 
plaster, or some plaster equally strong, is to be preferred. 

14 



Moore's apparatus. Front view. 



Fig. 53. 




Sayre's apparatus. 



202 



FRACTURES OF TPIE CLAVICLE. 



The first strip is looped around the arm just below the axillary 
margin, and pinned, or stitched, with the loop sufficiently open to avoid 
strangulation. The arm is then drawn downwards and backwards until 
the clavicular portion of the pectoralis major is put sufficiently on the 
stretch to overcome the sterno-cleido-mastoid, and thus draw the sternal 
fragment of the clavicle down to its place. The strip of plaster is then 
carried completely around the body, and pinned or stitched to itself on 
the back. 

The second strip is then applied, commencing on the front of the 
shoulder of the sound side, thence it is carried over the top of the 
shoulder, diagonally across the back, under the elbow, diagonally across 



Fig. 54. 



Fig. 55. 





the front of the chest, to the point of starting, where it is secured by 
pins or thread. A longitudinal slit is made in the plaster, to receive 
the point of the elbow. 

Before laying the plaster across the elbow, an assistant must press 
the elbow well forwards, and inwards, and it must be held firmly in this 
position until the dressing is completed. It will be now seen that the 
arm has been converted into a lever, whose fulcrum is the loop of adhes- 
ive plaster at the lower margin of the axilla; and upon this it is be- 
lieved that in a great measure the efficiency of the apparatus depends. 

Certainly it no longer depends upon the position of the elbow, which 
was at first carried back in order to render tense the clavicular fibres 
of the pectoralis major, since, for the purpose of converting the hume- 
rus into a lever, the elbow is subsequently drawn forwards, and the 
clavicular fibres of the great pectoral are again relaxed. If, therefore, 
the apparatus has any advantages over other modes of treatment, it is 
solely by its action upon the humerus as a lever ; but the fulcrum is 
too remote from the upper end of the humerus to act very efficiently. 
Great force has to be applied to secure this end, or at least so much 



FRACTURES OF THE CLAVICLE. 



203 



Fig. 56. 



force that, if steadily maintained, it is pretty sure to cause excoriations 
of the arm where the fulcrum acts ; or, as more often happens, it will 
speedily loosen, under the expansion and contraction of the chest in 
respiration, and thus cease to be efficient. Several cases of fractured 
clavicles, treated in Bellevue and St. Francis hospitals by this method, 
have come under my notice, and the results have been no better than 
when my apparatus has been used, while they have in most cases caused 
more discomfort. 

The sling, in some of its forms, is employed by Richerand, Huber- 
thal, Colles, Miller, Fox, Stephen Smith," 1 H. H. Smith, Bartlett, 2 
Levis, 3 Dugas, 4 Benjamin Bell, Bransby Cooper, Earle, Chapman, 
Keal, and by a large majority of the English surgeons. 

No apparatus, perhaps, has been so generally employed, among 
American surgeons, as that form of the sling introduced by Dr. George 
Fox into the Pennsylvania Hospital in 
1828. 

Sargent says of it : " Fractures of the 
clavicles, treated by this apparatus, are 
daily dismissed from the Pennsylvania 
Hospital, and by surgeons in private 
practice, cured without perceptible de- 
formity." 

Norris, in a note to Liston's Practical 
Surgery, affirms that "the chief indica- 
tions in the treatment of fracture of the 
clavicle are perfectly fulfilled by the 
use of this apparatus." 

H. H. Smith, in his Minor Surgery, 
declares that Fox's apparatus accom- 
plishes "perfect cures" in very many 
cases, and that it is "a very rare thing 
for a simple case to go out of the house 
(Pennsylvania Hospital) with any other 
deformity save that which time cures, 
viz., the deposition of the provisional 
callus." He has also repeated substan- 
tially the same opinion in his larger 
work, entitled Practice of Surgery. 

Such testimony in favor of any dress- 
ing demands respectful attention ; and 
I shall not be regarded as detracting 

from the respect due to these authorities, when I express my belief 
that it is in deference to the distinguished reputation of the surgeons 
who had during the preceding thirty years had charge of the services 
in that hospital, and who have been so loud in its praise, that the use 




E. Bartlett's Apparatus.—" For an ax- 
illary pad, roll a strip of woollen flan- 
nel, four or five inches wide, around the 
axillary strap, to the size required. The 
apparatus may be used for either side by 
changing the attachment of the sling." — 
Bartlett. 



1 Stephen Smith, New York Journ. Med., vol. ii, 3d series, p. 384 (Ma}', 1857). 

2 Bartlett, my "Report on Defor.," etc., Appendix; also, Bost. Med. and Surg. 
Journ., vol. ii, p. 404. 

3 Levi?, H. H. Smith's Practice of Surg., p. 365. Am. Journ. Med Sci., April, 
1860, p. 428. 

4 Dugas, Report on Surgery. 



204 



FRACTURES OF THE CLAVICLE. 



Fig 



of this apparatus has, with us, become so general. I must be per- 
mitted, however, to express a doubt whether it has made deformities of 
the clavicle " the exception, instead of the rule," with us. I have used 
this dressing in the early years of my practice, quite often, but my 
success has by no means been so flattering as has been the success of 
these gentlemen. I have seen others employ it, also, and with pretty 
much the same result. 

Fox's apparatus consists of a sling, made of muslin cloth ; a wedge- 
shaped axillary pad, made of muslin, also, stuffed, and half the length 

of the humerus; and of a stuffed collar. 
The axillary pad is not so thick or firm 
as Desault's pad, and for that reason is 
not likely to do harm. It is placed 
with its thickest end upwards, in the ax- 
illa corresponding to the broken clavicle, 
and secured in place by tapes attached 
to its upper end, and made fast to the 
stuffed collar upon the opposite shoulder. 
The sling is, in like manner, suspended 
from the stuffed collar. Finally, the 
hand is suspended over the front of the 
chest by a piece of muslin, looped under 
the wrist, and tied around the neck. No 
bandage is employed to confine the elbow 
to the body, and no effort is therefore 
made to convert the arm into a lever, 
and thus force the shoulder out. 

It will be understood that I am speak- 
ing of this dressing as it was employed 
some years ago, and when the gentlemen 
whom I have quoted spoke of it so ap- 
provingly. Since then it may have undergone many modifications, or 
it may have been laid aside altogether. 

It must be apparent to every practical surgeon that this apparatus 
could not answer " perfectly " all the indications of treatment, namely, 
to carry the shoulder up, out, and back, so that the clavicle would be 
made to unite without shortening or deformity. 

If, however, the writers intend only to say that no very serious, or 
very marked deformity usually ensues upon the plan of treatment, and 
in some cases none at all, then it will be proper to reply, that this 
amount of success may be attained by almost any form of dressing. 
It has been attained by myself with my own dressing, and with the 
dressing recommended by others. 

It will be further necessary to say that the absence or presence of a 
striking deformity, will depend very much upon the age of the patient, 
the character of the fracture — whether more or less oblique — upon the 
point at which the bone is broken, and upon the condition of the 
patient. It will be generally more marked, other things being equal, 
in thin or muscular persons, than in those who are fat and of small 
and feeble muscle. If the overlapping of the fragments is in the plane 




George Fox's apparatus. 



FRACTURES OF THE CLAVICLE. 205 

of the surface of the integument, the deformity will be less apparent 
than if one fragment lies in front of the other. 

Finally, while I deprecate incautious assumptions in regard to the 
capabilities of any form of dressing for broken collar-bones, a disposi- 
tion to which is manifested by more than one advocate of special plans, 
I am ready to declare my preference for an apparatus consisting essen- 
tially of a sling, axillary pad, and bandages to secure the arm to the 
chest. Among the considerable variety of dressings which I have used, 
this has seemed to me most simple in its construction, the most com- 
fortable to the patient, the least liable to derangement (if I except 
Velpeau's dextrin bandage, and certain other forms of "immovable" 
dressings), and as capable as any other of answering the several indi- 
cations proposed, while the patient is permitted to walk about. 

No apparatus is better able to answer the first indication, namely, 
to " carry the shoulder up," than the sling. Indeed, in nearly all the 
forms of dressing hitherto devised, the sling is employed for this pur- 
pose. The bandage carried beneath the elbow is, in effect, a sling. In 
a few instances, men of no practical experience have sought to substi- 
tute an upward pressure in the axilla for the sling; but it is scarcely 
necessary to declare the absurdity of this practice, inasmuch as no pa- 
tient will be found willing to submit to it beyond a few hours. 

It is proper to say, however, that some surgeons, whose opinions are 
entitled to respect, believe that it is quite as important to depress the 
sternal fragment as it is to elevate the acromial, the outer end of the 
sternal fragment being lifted, more or less, by the action of the sterno- 
cleido-mastoid muscle. No doubt this is one of the difficulties with 
which we have to contend in our efforts to restore the two fragments 
to the original line of the axis of the bone. 

Inclination of the head to the side of the fractured limb will allow 
the sternal fragment to fall ; but it is impossible for the patient to 
maintain this position for any length of time. A compress laid over 
the sternal fragment, and held in place by adhesive straps or bandages, 
will be found totally inefficient. Dr. Moore has adopted a more 
ingenious and philosophical method, by calling into requisition the 
clavicular fibres of the pectoralis major to antagonize the sterno-cleido- 
mastoid. Indeed, this is one of the essential principles upon which he 
rests the superior claims of his dressing; and I have myself observed 
that when, in the case of a recent fracture, the elbow is thrust behind 
the body, the outer end of the sternal fragment is depressed. Never- 
theless, I have certain theoretical and practical objections to the doc- 
trine as taught so ingeniously by Dr. Moore. My theoretical objection 
is that the clavicular fibres of the stern o-cleido- mastoid will soon, under 
the continual strain, become relaxed, and after a little time cease to 
accomplish what they did at first. This is a law in regard to the action 
of muscles put upon the strain, as every surgeon knows. It may be 
supposed that if the pectoral muscle is thus rendered less competent to 
depress the fragment, the sterno-cleido-mastoid will be rendered, also, 
less competent to elevate the fragment ; but this is not strictly true : 
the latter operates at right angles with the axis of the bone, and to 



206 FRACTURES OF THE CLAVICLE. 

great advantage, while the former acts very obliquely, and to a corre- 
sponding disadvantage. 

The practical objection which I have to offer is, that the dressings 
required to maintain this position are exceedingly liable to cause exco- 
riations and to become disarranged, and that in fact this has happened 
in all, or nearly all, of the cases which have been observed by me. 
Moreover, whatever cause may be assigned for the failure, the results 
have been no better, so far as overlapping and deformity are concerned, 
than when my own dressings have been used. 

The second indication, namely, "to carry the shoulder back," is 
certainly more difficult of accomplishment than the first, and it is only 
imperfectly met by my own method, or by any other form of sling 
dressing. Desault taught that when the arm was lifted by the sling, 
or by any mode of pressure beneath the elbow perpendicularly, the 
shoulder was necessarily carried back. This is probably true, but its 
effect is not very marked. The ordinary figure of 8, which might at 
first be supposed to be the most rational mode of effecting this purpose, 
has long since been proven to be a failure. None of the contrivances 
to hold the shoulders back by bands which traverse the axilla, made 
fast to back splints, have done any better. They all cause excoriations, 
and soon become intolerable. Dr. Sayres's adhesive plaster band, 
attached to the upper part of the humerus, below the axillary margin, 
either loosens or excoriates, also, and in the end proves inefficient. 

After all it must be said, that the indication " to carry the shoulder 
back," except in so far as it incidentally accomplishes the indication "to 
carry the shoulders out," and thus obviate the overlapping of the frag- 
ments, is relatively unimportant. It is seldom that the falling forward 
of the shoulders is very marked, or in itself a source of deformity; but 
carrying the shoulder back does diminish or overcome the riding of 
the fragments, and in this view alone is it important, and for this 
reason, surgery will be indebted to any one who devises a method by 
which this position of the shoulder can be maintained until the union 
of the fragments is consummated. 

The third indication is "to carry the shoulder out," by which means 
it is proposed to overcome, directly, the riding of the fragments. We 
have seen that this may be accomplished, indirectly, by carrying the 
shoulder back ; but, unfortunately, no means has yet been found by 
which this can be done and permanently maintained. 

The thick axillary pad, and all other devices by which it is proposed 
to act upon the humerus as a lever, and thus force the shoulder out, 
have totally failed or proved eminently mischievous. In short, I may 
say that this indication can, in my opinion, be effectually accomplished 
in only one way, and that is, by laying the patient upon his back on 
a flat, firm mattress, and thus pressing the base and inferior angle 
of the scapula strongly and steadily against the back. The requisite 
pressure upon the scapula cannot be maintained by any plan yet con- 
trived while the patient is in the sitting or standing posture, and espe- 
cially when permitted to walk about. Its application must, there- 
fore, be limited to rare and exceptional cases. If a slight overlapping 
and deformity were to cause any appreciable diminution of the strength 



FRACTURES OF THE CLAVICLE. 



207 



or usefulness of the arm, patients might properly enough be subjected 
to such restraints for a few weeks ; but experience has shown that such 
displacements do not, in any degree, maim the arm. Whether in the 
case of women, in examples of unusual displacement, the danger of 
disfigurement would warrant a resort to this method, must be left to 
the judgment of the surgeon and the choice of the patient ; but in 
adopting what may be termed the " posture " treatment, it will be 
advisable, also, to employ the sling, pad, and bandages in the manner 
hereafter to be described. 

The mode of dressing a fractured clavicle which, while the patient 
is at liberty to walk about, will secure the best results with the least 
suffering and annoyance, is as follows : 

The arm hanging perpendicularly beside the body, a sling is placed 
under the elbow and forearm, and tied over the opposite shoulder. An 



Fig. 58. 




The author's dressing for fractured clavicle. 



axillary pad, composed of cotton batting inclosed in a cloth cover, is 
placed well up in the axilla, and the elbow is then secured firmly to 
the side of the body with several turns of a roller. 

Dr. Coates, in the excellent paper already referred to, calls attention 
to the danger of making too much pressure upon the brachial artery 



208 FRACTURES OF THE CLAVICLE. 

and nerves, when the axillary pad is used, and the arm is, at the same 
time, carried forwards upon the body. In bringing the elbow for- 
wards, so as to lay the forearm across the body, the humerus is made 
to rotate inwards, and the brachial artery and nerves are brought into 
more direct apposition with the pad ; 1 while in the position which I 
have recommended and practiced hitherto, these nerves and vessels are 
removed in a great measure, but not entirely, from pressure. 

The pad should be no thicker than is necessary to fill completely 
the axillary space, its purpose being to steady the arm, and, in some 
slight degree, to counteract the action of those muscles which tend to 
displace the shoulder inwards. It should be long enough in its antero- 
posterior diameter to project distinctly in front and behind, otherwise 
it will not keep its place. In the adult it needs to be six or seven 
inches long. In the direction of the axis of the limb, its length should 
be less, perhaps four inches. Being now well pressed up into the 
axilla, and secured with a needle and thread to the upper edge of the 
roller which encircles the lower part of the arm and the body, it will 
keep its position and serve some useful purpose. 

The sling may be made of cotton or flannel cloth, and suspended 
from the opposite shoulder by the aid of four tapes, a broad and thick 
pad of folded cloth being laid upon the shoulder to support the knots. 
A considerable experience has satisfied me that the stuffed collar, used 
in the Fox dressing, possesses no advantage as a means of suspension. 
The leather sling, also, in use at some hospitals, is liable to the objec- 
tion that it cannot be stitched to the roller, which encircles the body 
and lower part of the arm, in the manner I shall hereafter describe. 

The roller should be made to encircle the lower fourth of the arm, 
and a few turns should pass beneath the forearm as far forwards as the 
hand, in this manner securely fixing the elbow and forearm against 
the side and front of the body. 

If thought necessary, the hand may be supported by a loop of band- 
age passed under the wrist and tied over the neck. 

Finally, in order that this dressing may retain its place and serve 
its purpose most effectually, its several parts should be stitched together 
thoroughly wherever the dressings cross or approach each other. In 
no other way can anything like permanency be insured in a portion of 
the body so movable as the shoulder and chest; but even with this 
precaution, daily attention and frequent readjustment are generally 
required. 

Treatment of Incomplete Fractures of the Clavicle. — In case of partial 
fracture of the clavicle, accompanied with a persistent bend in the line 
of the axis of the bone, it is proper to attempt the replacement of the 
fragments by direct pressure. The ends of the bone being fixed, we 
cannot, as in the case of a partial fracture of other long bones, employ 
leverage; and with direct pressure alone, applied in a degree which 
might be regarded as incurring no danger of causing a complete frac- 
ture or of a dislocation, our chances of success are very small. I can- 
not say that I have ever succeeded in accomplishing anything in this 

1 Coates, Am. Journ Med. Sci., vol. xviii, p. 62. 



FRACTURES OF THE BODY OF THE SCAPULA. 209 

way, although I have often made the attempt, and would always advise 
others to do the same. A failure, however, to restore completely the 
line of the axis of the bone is not, I imagine, a matter of great conse- 
quence, since, as has already been fully explained when speaking of 
partial fractures in general, the natural form will be in most, if not in 
all cases, completely restored after the lapse of a few months or years. 
This observation applies especially to partial fractures occurring in 
childhood and infancy. I have no experience as to what is the result 
of a similar deformity left after a partial fracture in the adult. 

As to the method of dressing these fractures, it need not differ from 
that recommended for complete fractures ; but in a majority of these 
cases I have thought it sufficient to place the arm in a sling, with a 
bandage around the elbow and body to keep the arm at rest, or I have 
directed the mother to make the sleeve fast to the front of the dress 
with tapes. The axillary pad can seldom, if ever, serve any useful 
purpose. 

Union occurs with great rapidity, sometimes as early as the seventh 
or tenth day ; but the arm ought to be kept quiet, as a matter of safety, 
two or three weeks. 

For a more full consideration of the subject of partial fractures of 
the clavicle, the reader is referred to the chapter on " Incomplete 
Fractures/ 7 



CHAPTER XIX. 

FRACTUKES OF THE SCAPULA. 

Fractures of the scapula may be divided into those which occur 
through the body, the neck, the acromion process, and the coracoid. 

\ 1. Fractures of the Body of the Scapula. 

Under this title I propose to consider not only fractures of the 
u body," properly speaking, but also fractures of the angles and of the 
spine. 

Causes.— The scapula is usually broken by the fall of some heavy 
body directly upon the bone, or by some severe crushing accident, by 
the kick of a horse, by a fall upon the back ; in short, by direct causes 
alone, and by such causes as operate with great violence. 

Malgaigne says that a Doctor Heylen has recently published a case 
of this fracture which he believes to have been the result of muscular 
action, occurring in a man forty-nine years old. The case, however, 
is not stated so clearly as to relieve us entirely of a doubt as to the 
nature and cause of the accident. 

I have myself recorded six cases which have been under my treat- 
ment ; and I have lately seen two other examples of fractures of the 
body of the scapula not caused by firearms. There are two cabinet 
specimens of fracture of the body of the scapula below the spine in 



210 



FRACTURES OF THE SCAPULA. 



the Pennsylvania Medical College, and two involving the spine. Dr. 
Miitter had in his collection a fracture of the posterior angle, and Dr. 
March had a specimen of fracture of the body. I believe also that in 
the collection of the late Dr. Charles Gibson, of Richmond, there were 
one or two specimens of this fracture. I know of no other museum 
specimens in this country except my own of partial fracture, described 
in the chapter on Partial Fractures. 

Ravaton, after a practice of fifty years, declared that he had never 
seen a fracture of the scapula except as it had been produced by fire- 
arms. Among 2358 fractures reported from Hotel Dieu during a 
period of twelve years, only four examples of fracture of the scapula 
are recorded ; and at Middlesex Hospital, Lonsdale has noticed, among 
1901 fractures, only eight of the body of the scapula. 

The infrequency of this fracture is no doubt due in a great measure 
to the elasticity of the ribs, to the mobility of the scapula, and to the 
softness of the muscular cushion upon which it reposes. 

Symptoms. — Since this bone is seldom broken except by great force 
directly applied, the usual signs of fractures are likely to be con- 
cealed by the speedy occurrence of swelling. It is for this reason that 
it becomes necessary, generally, that the examination should be made 

with great care before we can 
fig. 59. safely determine upon the 

diagnosis. I have more than 
once had occasion to correct 
the diagnosis of other prac- 
titioners, who believed they 
had discovered a fracture of 
the scapula. 

When, however, the line 
of the fracture has traversed 
the spine, and any consider- 
able displacement has occur- 
red, one may recognize the 
fracture easily by merely car- 
rying the finger along the 
crest. 

If the fracture has occur- 
red through the body, below 
or above the spine, or through 
either of the angles, the dis- 
placement may not be so 
easily recognized. The sur- 
geon ought then to trace 
carefully with his finger the 
outlines of the scapula ; and 
this he will be able to do more 
satisfactorily if he places the 
scapula in such positions as 
elevate its margins and render them more prominent. In examining 
the posterior angle, the hand of the injured limb may be placed upon 




Fracture of the posterior angle of scapula, with fissure. 
Mutter's collection, Specimen C, No. 187. 



FRACTURES OF THE BODY OF THE SCAPULA. 



211 



the opposite shoulder, the forearm being carried across the front of the 
chest ; but in searching for a fracture below the spine, the forearm 
ought to be laid across the back. 

Crepitus, which is not always present, owing to the fact that the 
fragments overlap completely, or because they have been widely sepa- 
rated by the action of the muscles, may generally be detected by placing 
the palm of the hand upon some portion of the scapula, so as to steady 
the fragment upon which it rests, while the arm is moved backwards 
and forwards, and in various other directions, until their broken surfaces 
are brought into contact. 

Some degree of embarrassment in the motions of the shoulder and 
arm must always result from this fracture ; sometimes this embarrass- 
ment is very great, but it ought not to be considered ever as diagnostic 
of a fracture, since it may be produced equally by a severe contusion ; 
and even when it is accompanied with a fracture, it is due rather to 
the contusion than to the fracture. 

Pathology, Seat, Direction, etc. — Of incomplete fractures of the 
scapula, I have already mentioned that I have seen one example. 

Malgaigne thinks that he has seen one case of incomplete fracture, 
which occurred in a man who was injured by the fall of a heavy block 
of stone upon his back ; but as the patient recovered, his diagnosis 
must remain doubtful. I know of no other recorded examples. 

Complete fractures occur most often below the spine, and they are 
generally oblique or transverse, sometimes nearly longitudinal. 

Fractures involving the spine are noticed occasionally; but I am 
not aware that any one has ever seen a specimen of a fracture of the 
spine alone, although many surgeons have 
spoken of them. 

I have mentioned one example of a frac- 
ture of the posterior angle as being in the 
cabinet of Dr. Mutter, of Philadelphia. 
Malgaigne seems to doubt its existence, 
but speaks of it as a fracture which sur- 
geons have " imagined." 

Occasionally the bone is broken into 
more than two fragments. 

As a result of the fracture there is usu- 
ally more or less displacement ; generally, 
if the fracture is below the spine and trans- 
verse, and especially if its direction is ob- 
lique from before backwards and down- 
wards, the inferior fragment is displaced 
forwards, or forwards and upwards, by the 
action of the serratus major anticus, or of 
the teres major, while the superior frag- 
ment is inclined to fall backwards, and sometimes it is carried upwards 
and backwards, following the action of the rhomboideus major. 

In cases of comminuted fractures, and occasionally in simple frac- 
tures, the direction of the displacement is reversed, or altogether 
changed, so that the lower fragment, instead of being in front, is be- 



Fig. 60. 




Fractures of the body and acromion 
process of the scapula. 



212 FRACTURES OF THE SCAPULA. 

hind the upper fragment ; and instead of overlapping, the two fragments 
are more or less drawn asunder. These are deviations which are not 
easily explained, but which depend, perhaps, rather upon the direction 
of the blow than upon the action of the muscles. 

In a few cases there is no displacement in any direction, although 
the crepitus with mobility sufficiently demonstrate the existence of a 
fracture. 

Prognosis. — If displacement actually has taken place, it will be found 
very difficult, as we shall see when we come to consider the treatment, 
to hold the fragments in apposition until a cure is completed ; so that 
they are pretty certain to unite with a degree of overlapping, or other 
irregularity. 

Lonsdale, Lizars, Chelius, Nelaton, Gibson, Malgaigne, and others 
have spoken of the difficulty or impossibility generally of keeping 
these fragments in place. Nelaton and Malgaigne, indeed, confess that 
they have never succeeded; Gibson declares that it is scarcely possible; 
while Chelius affirms that if the fracture is near the angle, the cure is 
always effected with some deformity. 

But then it is not probable that the patient will ever suffer any seri- 
ous inconvenience from this irregular union of the fragments, since the 
perfection of its function depends less upon any given form or size than 
in the case of almost any other large bone; and if, as has been observed 
by Lonsdale,, the free use of the arm is not recovered for some time, or 
if, as has been noticed by B. Bell, a permanent stiffness results, these 
should be regarded as due to the injury which those muscles have 
suffered which envelop the scapula, or to some injury of the ligaments 
and muscles which surround the shoulder-joint. 

In some few examples upon record, the bone has been so comminu- 
ted, and the soft parts adjacent so much injured, that suppuration and 
necrosis have ensued. And in one case of gunshot fracture of the scap- 
ula, attended with much comminution, and resulting in necrosis, I 
have had occasion to remove the entire scapula. 

Treatment. — In the treatment of this fracture, the first object with all 
surgeons has been to restore the fragments to place, and this they have 
chiefly sought to accomplish by position ; after which they have endeav- 
ored to immobilize the fragments by bandages, etc. 

In seeking to accomplish the first indication, they have placed the 
shoulder and arm in a great variety of postures. Nearly all seem to 
have regarded it as of some importance that the shoulder should be 
elevated, so as to relax the muscles attached to the upper and back part 
of the scapula, and thus permit the upper fragment to fall downwards 
and forwards. 

If we confine our remarks first to fractures through the body, and do 
not include fractures of the inferior angle, this indication is the only 
one which Nelaton and Mayor have sought to accomplish, and for this 
purpose they employ a simple sling; while Amesbury, Listen, Lons- 
dale, S. Cooper, South, Skey, Miller, Pirrie, have added to the sling a 
bandage or roller, which is made to inclose snugly the body and arm. 

Erichsen uses the body bandage alone, as in fractures of the ribs, 
while B. Cooper, Lizars, and Tavernier employ a bandage which in- 



FRACTURES OF THE BODY OF THE SCAPULA. 213 

closes not only the body, but also the arm; neither of these last-men- 
tioned surgeons recommends a sling, or any other means to elevate the 
arm. 

Johannes de Gorter advises that a sling shall be used, but that the 
elbow shall be lifted away from the side of the body, so as to relax the 
deltoid. Chelius and Desault recommend the same position, but with 
the addition of an axillary pad, whose apex shall be directed upwards, 
secured in place with appropriate bandages. 

Pierre d'Argelata used also an axillary pad, but instead of a wedge 
he recommended a simple roll; and instead of lifting the elbow away 
from the body, he directed that the elbow should be secured against the 
side, making use of the axillary roll as a fulcrum. 

Petit and Heister advised that the elbow and forearm should be car- 
ried forwards upon the front of the chest, and secured in this position. 

In the treatment of no other fracture perhaps have surgeons differed 
more widely as to the indications than in this, since, as we have seen, 
some recommend the elbow to be carried from the body, and some that 
it shall be made to approach the body; one directs that the elbow shall 
fall perpendicularly beside the chest, a second prefers that it shall be 
carried a little back, and a third that it shall be brought well forwards. 
In one thing alone have they nearly all agreed, namely, that the elbow 
shall be lifted ; and generally also it has been recommended that the arm, 
forearm, and body shall be confined by sufficient bandages to insure 
quietude. It might be proper to conclude, therefore, that the sling and 
bandage constitute all of the apparatus which is necessary or useful ; 
and that it is relatively unimportant whether the elbow is near or re- 
mote from the body, or whether it is in front of, or behind, or beside 
the chest. 

Such, indeed, is the conclusion to which we have ourselves arrived; 
yet if, in relation to the position of the elbow, a choice were to be ex- 
pressed, we would give the preference to that in which the arm is laid 
vertically beside the body, or, perhaps, with the elbow a little inclined 
backwards, so as to relax as completely as possible the teres major. 

It is quite probable, however, that no single position will be found 
of universal application; and perhaps it would be more safe to advise 
the surgeon in any given case first to reduce the fragments as com- 
pletely as possible by manipulation, and then to place the arm in such 
a position as, upon careful experiment in this particular instance, he 
shall find enables him to best retain them in place. 

If, however, the fracture is such as to have separated the inferior 
angle from the body, it will be well to follow the advice of Boyer and 
of others, and to place a compress in front of the inferior angle, to resist 
the greater tendency to displacement in this direction. This compress 
will more effectually accomplish this indication if the roller with which 
it is secured to the body, and with which we seek to immobilize the 
scapula and chest, is turned from before backwards, or in a direction 
of antagonism to the action of the muscles which produce the dis- 
placement. 

Desault, with Chelius and Bransby Cooper, has recommended also, 
in the case of a fracture through the angle, that the forearm should be 



214 



FRACTURES OF THE SCAPULA. 



acutely flexed upon the arm, and that the hand should be placed in 
front of the chest, upon the sound shoulder, a position which is always 
irksome, and sometimes insupportable, and which does not offer in any 
case sufficient advantages to render it worthy of a trial. 

I 2. Fractures of the Neck of the Scapula. 

If by the " neck " of the scapula surgeons mean that slightly con- 
stricted portion of this bone which is situated at the base of the glenoid 
cavity — and it is to this portion, we believe, that anatomists have gen- 
erally applied the term "neck" (we will take the liberty of calling this 
the "anatomical" neck) — then its fracture is certainly very rare. In- 
deed, the existence of this fracture, uncomplicated with a comminuted 
fracture of the glenoid cavity, is denied by Sir Astley Cooper, South, 
Erichsen, and others. Mr. South says there is no such specimen in 
any of the museums in London; and I have not been able to find one 
in any of the American cabinets. Dr. Valentine Mott has said to me 
that he had never seen a specimen, and that in the natural condition of 
the bone he regards its occurrence as impossible. Such, I confess, also, 
is my own conviction. 

If, however, it is intended, in speaking of fractures of the neck of 
the scapula, to refer, as Sir Astley Cooper has done, only to fractures 
extending through the semilunar notch, behind the root of the coracoid 
process ("surgical" neck), then its existence is certain; yet the frac- 
ture is not common. Duverney has reported one example, the exist- 



Fig. 61. 



Fig. 62. 





Comminuted fracture of the glenoid 
cavity. 



Fracture of the neck of the scapula; according to 
Sir Astley Cooper. 



ence of which he established by a dissection. The coracoid process 
was broken at the same time, but the fracture through the surgical 
neck w T as distinct from this ; and Sir Astley has recorded three ex- 
amples in which the diagnosis was very clearly made out, yet not actu- 
ally proven by an autopsy. 



FRACTURES OF THE ACROMION PROCESS. 215 

In Holmes's Surgery it is stated that there is one specimen in the 
museum of Guy's Hospital ; another, in which repair has taken place, 
in the museum of the Royal College of Surgeons; and the writer re- 
fers, also, to the case reported by Duverney in 1751. 1 

Perhaps some of the cases, diagnosed during the life of the patient 
as fractures of the neck of the scapula, were fractures of the lower or 
anterior lip of the glenoid cavity; but I have never found such a 
specimen in any collection of bones which I have yet examined, and 
it must be admitted to be exceedingly rare. 

Symptoms. — Sir Astley Cooper justly remarks that " the degree of 
deformity produced by a fracture of the surgical neck of the scapula 
depends upon the extent of laceration of a ligament which passes from 
the under part of the spine of the scapula to the glenoid cavity. If this 
be torn " (and to this we ought to add the ligaments passing from the 
coracoid process to the clavicle and acromion process — coraco-clavicu- 
lar and coraco-acromial), " the glenoid cavity and the head of the os 
humeri fall deeply into the axilla, but the displacement is much less if 
this remains whole." 

The usual signs are, a depression under the acromion process, the 
same as in dislocation of the head of the humerus downwards, but not 
so deep; the head of the humerus felt, perhaps, in the axilla; crepitus, 
and the immediate recurrence of the displacement whenever, after the 
reduction has been fairly accomplished, the arm is left unsupported. 
The crepitus is best discovered by resting one hand upon the top of 
the shoulder in such a manner as that a finger shall touch the point of 
the process, while the arm is rotated and moved up and down by the 
opposite hand. It may also be easily ascertained that the coracoid 
process moves with the humerus instead of the scapula. Occasionally 
the accident is accompanied with paralysis of the arm, from pressure 
upon the axillary nerves ; and a rupture of the axillary artery is also 
mentioned by Dugas. 2 

Treatment. — The indications of treatment are three, namely, to carry 
the head of the humerus, with the glenoid cavity, etc., up, to carry it 
out, and to confine the body of the scapula. The first is accomplished 
by a sling, the second by a pad in the axilla, and the third by a broad 
roller carried repeatedly around the arm and chest and across the 
shoulder. In short, the treatment is essentially the same as that which 
we have recommended for a broken clavicle. 



I 3. Fractures of the Acromion Process. 

Examples of fracture of the acromion process have been reported 
by Duverney, Bichat, Avrard, A. Cooper, Desault, Sanson, Nelaton, 
Malgaigne, West, 3 Brainard, 4 Stephen Smith, and others. I have 

1 Holmes's Surgery, vol. ii, p. 776, Amer. ed., 1870. 

2 Kemarks on Frac. of Scapula, by L. A. Dugas, Georgia. Amer. Journ. Med. 
Sci , Jan. 1858 

3 West, Penin. Journ. of Med., vol. v, p. 254. 

4 Brainard, Bost. Med. and Surg. Journ., vol. xxxi, p. 501. 



216 FRACTURES OF THE SCAPULA. 

myself reported three examples ; l and one more example has come 
under my notice since the date of that report. 

In the case seen by Cooper it entered the articulation of the clavicle, 
and produced at the same moment a dislocation. Malgaigne says it 
occurs generally farther up, and posterior to the attachments of the 
clavicle, " near' the junction of the diaphysis with the epiphysis," and 
that the fracture is in most cases transverse and vertical ; but Nelaton 
saw a case in which the fracture was oblique. In the case reported by 
C. West, of Hagerstown, Md., the fracture was through the base of 
the process. In two of the examples seen by me the fracture was in 
front of the clavicle ; in the third, occasioned by the fall of a barrel of 
flour upon the shoulder, the fracture occurred at the acromio-clavicular 
articulation, and was accompanied with an upward dislocation of the 
outer end of the clavicle ; and in the fourth the fracture occurred at the 
same point, but there was neither displacement of the clavicle or of the 
process, the fracture being only recognized by the crepitus and motion. 

There is some reason to believe, I think, that a true fracture of the 
acromion process is much more rare than surgeons have supposed, 
and that in a considerable number of the cases reported there was 
merely a separation of the epiphysis ; the bony union having never 
been completed. If such fractures or separations occurred only in 
children very little doubt might remain as to the general character of 
the accident ; but the specimens which I have found in the museums, 
and the cases reported in the books, have been mostly from adults. It 
is more difficult, therefore, to suppose these to be examples of separa- 
tion of epiphyses, but I am inclined to think that in a majority of 
instances such has been the fact. It is very probable, also, that in the 
case of many of the specimens found in the museums, called fractures, 
the histories of which are unknown, they were united originally by 
cartilage, and that in the process of boiling, or of maceration, the dis- 
junction has been completed. The narrow crest of elevated bone 
which frequently surrounds the process at the point of separation, and 
which Malgaigne may have mistaken for callus, is found upon very 
many examples of undoubted epiphyseal separations which I have ex- 
amined ; and this circumstance, no doubt, has tended to strengthen the 
suspicion that these were cases of fracture. 

This opinion is confirmed by the remark of Mr. Fergusson, that a 
fracture of this process is an accident " of rare occurrence." " I have 
dissected," he adds, "a number of examples of apparent fracture of the 
end of this process ; but in such instances it is doubtful if the movable 
portion had ever been fixed to the rest of the bone." Dr. Jackson says 
there are four specimens in the museum of the Massachusetts Medical 
College, and in the museum of the Boston Society for Medical Im- 
provement, which might easily be mistaken for fractures, but which 
only illustrate to how late a period the bony union is sometimes de- 
layed. In one specimen the patient could not have been less than forty 
years of age ; " the acromial process of each scapula was fully formed, 
but having no bony union whatever with the bone itself. The union 
was ligamentous, but strong and close." 

1 Keport on Deformities. 



FRACTURES OF THE ACROMION PROCESS. 



217 



To the same class belong several specimens in my own collection ; 
specimens 163 and 997 in Dr. March's collection ; 707 in the Albany 
College collection • two specimens in the Mutter, and one in the Jeffer- 
son Medical College museums. 

I wish to mention, also, that in the case of my own specimens of 
epiphyseal separation, as well as most of the specimens which I have 
examined, the ends of the fragments were closed with a compact bony 
tissue. 

The mode of development of the scapula will explain these cases. 
The scapula is formed from seven centres ; namely, one for the body, 
one for its posterior border, one for its inferior border, two for the 
acromion process, and two for the coracoid. Ossification of the body 




Scapula, with epiphyses. (From Gray.) 



exists to a certain extent at or near the period of birth. It commences 
in one of the centres of the coracoid process, about one year after birth, 
and unites to the body at about the fifteenth year. All the other 
centres remain cartilaginous until from the fifteenth to the seventeenth 
year, when ossification commences, and is completed by a common 
union among all parts, usually between the twenty -second and twenty- 
fifth years. 

No doubt, however, a fracture of this process does occasionally take 

15 



218 FRACTURES OF THE SCAPULA. 

place. In addition to my own, I have already mentioned several other 
examples, some of which have been confirmed by dissection, and in the 
case mentioned by Stephen Smith, an autopsy, made three weeks after 
the accident, showed a fracture without displacement, the periosteum 
covering its upper surface not being torn ; the fragment could be turned 
back as upon a hinge. 

Prognosis. — The process generally unites with a slight downward 
displacement. This occurred in at least two of the examples seen by 
me ; but in such cases the motions of the arm are not in consequence 
much, if at all, impaired ; unless, indeed, it is so much depressed as to 
interfere with the upward movements of the arm ; a result which 
Heister erroneously supposed was inevitable. 

Sir Astley Cooper says that a true bony union is rare in these frac- 
tures, and that there generally results a false joint, the fragments 
uniting by a fibrous tissue; but sometimes the surfaces, instead of 
uniting either by bone or ligament, become polished, and even ebur- 
nated. 

Malgaigne has noticed, also, in a specimen contained in the Dupuy- 
tren museum, a hypertrophy of the lower fragment, this portion having 
a diameter nearly twice as great as that of the portion from which it 
was detached. 

Symptoms. — Where no displacement exists, the diagnosis must always 
be difficult, if not impossible. In such a case we could only be in- 
structed by the manner in which the injury had been received, by the 
contusion, and by the presence of mobility or crepitus. 

In examples attended with displacement, if no swelling is present, 
the finger carried along the spine of the scapula to its extremity, will 
easily detect the fracture by the abrupt termination of the process, or 
by the presence of a fissure, or a depression ; but as to the other symp- 
toms, they must depend very much upon the point at which the frac- 
ture has taken place. If in front of the acromio-clavicular articulation, 
the position of the arm in its relations to the body will not be changed ; 
but if the fracture is through the articulation, and a dislocation of the 
clavicle results, or if it is behind the acromio-clavicular articulation, 
the arm, having in either case lost the support of the clavicle, will 
assume the same position that it does in a fracture of the clavicle ; that 
is, the shoulder will fall downwards, inwards, and forwards. 

Treatment. — If the fracture has taken place in front of the acromio- 
clavicular articulation, no doubt the most rational plan of treatment, 
if one aims at the accomplishment of a perfect bony union, is that 
recommended by Delpech; that is, placing the patient in bed, upon his 
back, and carrying the arm out from the body nearly to a right angle ; 
since by this method the fragment is not only lifted, but the deltoid 
muscle is relaxed, and, consequently, the fragment is no longer forcibly 
drawn away from the spine of the scapula. If, therefore, the patient 
will submit to this treatment for a sufficient length of time, the union 
must be accomplished with the least possible amount of displacement. 
But in the case of a fracture of the acromion process at the point indi- 
cated, only a few fibres of the deltoid muscle are attached to the frag- 
ment which has been broken off, and consequently, even in case no union 



FRACTURES OF THE ACROMION PROCESS. 219 

took place, the muscular power of the arm could not be appreciably 
impaired. Nor would a slight falling or depression of the fragment 
cause any embarrassment to the motions of the shoulder-joint. 

For these reasons it is scarcely worth while to do anything more, in a 
great majority of cases, than to place in the axilla a pretty heavy wedge- 
shaped pad, with its apex upwards, and then secure the arm to the 
side with a sling and roller, the same as in the case of a fracture of the 
clavicle. 

If, however, the fracture has taken place at or behind the junction 
of the clavicle with the process, the indications of treatment will be, in 
all respects, the same as in the case of a fracture of the clavicle. 

1 4. Fractures of the Coracoid Process. 

"The coracoid process/' says Mr. Lizars, "is said to be broken off, 
but this I question very much ; it must be along with the glenoid 
cavity, or there must be a fracture of the neek of the scapula." 

Dr. Neill, of Philadelphia, has in his cabinet a specimen of separa- 
tion of this process at about one inch from its extremity. The line of 
separation is somewhat irregular ; there is no callus, but it is united 
to the upper portion by a dried tissue, half an inch in length, and con- 
tinuous with the periosteum. This has been regarded as an example 
of fracture ; but although the scapula is large, and evidently belongs to 
an adult, the fact that the acromion process is not yet united by bone 
renders it probable that this, also, is an epiphyseal separation. Prof. 
Charles Gibson, of Richmond, Va., has informed me also that he has 
in his cabinet a dried specimen, from an adult, which has been broken 
obliquely near the end, but which is now united by a ligamentous or 
fibrous tissue of one line and a half in length. The fragment is dis- 
placed a little forwards as well as downwards. Reuben D. Mussey, 
of Cincinnati, possessed a very remarkable and conclusive example of 
this fracture. The humerus is dislocated forwards, the head and neck 
being firmly united to the neck and venter of the scapula, w T hile at the 
same time the coracoid process is broken and displaced. Dr. Jackson, 
of Boston, says that specimen No. 453 in the museum of the Massa- 
chusetts Medical College seems clearly to have been a fracture involv- 
ing the base of the coracoid process, and which, having taken place 
somewhere within a year of the death of the person, had become united 
by bone, and that just before death the process had broken off, and so 
completely, as to involve a portion of the glenoid cavity. 1 

Bransby Cooper relates a case of fracture through the base, which 
after eight weeks, when the patient died, was found to be united by a 
ligament. The acromion process was broken at the same time, and 
had united in the same manner. The head of the humerus was also 
broken and partly united. 2 One example is said to have occurred in 
the practice of Dr. Arnott, at the Middlesex Hospital, London, in 
consequence of which the patient died, when a dissection disclosed the 

1 The author's Report on Deformities, op. cit. 

2 B. Cooper, edition of Sir Astley on Frac. and Disloc., Amer. ed., p. 380. 



220 



FRACTURES OF THE SCAPULA. 



Fig. 64. 



true nature of the accident. 1 Mr. South has also reported a case resem- 
bling somewhat Mussey's, but much more complicated. The humerus 
was partially dislocated forwards, the clavicle, acromion process, and 
the olecranon were broken as well as the coracoid process. Neither 
the fracture of the clavicle nor of the coracoid process was made out 
until after the patient died, which was on the fourth day ; the fact of 
the existence of these fractures being then ascertained by dissection. 2 
Holmes has reported a case. 3 Erichsen says there is in the museum of 
the University College a preparation showing a fracture at the base of 
this process, the line of fracture extending across the glenoid cavity. 4 
Duverney, Boyer, and Malgaigne have also reported four additional 
examples, confirmed by dissections. 5 

The existence of this form of fracture, established by at least nine 
or ten dissections, can no longer be denied ; yet it is usually accom- 
panied with serious complications, such as must in most cases prove 

fatal. In the only two cases, how- 
ever, in which I have had reason to 
believe that I had to deal with a 
fracture of this kind, the symptoms 
and termination were less grave, al- 
though they w r ere both complicated 
with an upward dislocation of the 
outer end of the clavicle. A gentle- 
man residing in the country was 
struck by a board which fell edge- 
wise upon his shoulder. The frac- 
ture of the coracoid process does not 
seem to have been recognized by his 
surgeon. An apparatus was applied 
to retain the clavicle in its place, 
but after three months, when he 
called upon me, it still remained 
displaced as at first. During all of this time the apparatus had been 
steadily kept on. On laying off the dressing, I discovered that the 
coracoid process was detached, obeying constantly the movements of 
the head of the humerus, but being not at all subject to the movements 
of the scapula. Some months later I examined the arm again, and 
found the parts in the same condition as before, but the functions of 
the arm were not impaired. A girl was admitted to Belle vue Hospital 
in November, 1868, having fallen upon her left shoulder, and having 
sustained a complete luxation of the acromial end of the clavicle, up- 
wards and outwards. Upon careful examination, a fracture of the 
coracoid process was also diagnosticated, indicated by both mobility 
and crepitus. 




Fracture of the coracoid process. 



1 Arnott, Fergusson's Surg., p. 213. 

2 South, Lond. Med.-Chir. Rev., 1810, vol. xxxii, new series, p. 41, 

3 Holmes, Med.-Chir. Trans., vol. xli, p. 447. 

4 Erichsen, Surgery, p. 207. 

6 Malgaigne, op. cit., p. 51U. 



FRACTURES OF THE HUMERUS. 221 

Tt has been generally stated that when this process is broken off, it 
will be carried downwards by the united action of the pectoralis minor, 
the short head of the biceps, and the coraco-brachialis muscles; but 
this will depend upon whether the coraco-clavicular ligaments are rup- 
tured also; a circumstance which is not very likely to occur, at least 
to any great extent; and in fact not one of the well-attested examples 
of this fracture has ever been accompanied with any considerable dis- 
placement in this direction. 

Treatment. — In a case of simple fracture of the process, unattended 
with any other lesions, it has been recommended to place the arm in a 
sling, with the elbow advanced as much as possible upon the front of 
the chest, as by this position we relax somewhat all of the three mus- 
cles having attachments to this process, and then to confine the scapula 
by a few turns of a roller. It is not probable, however, that by these 
measures we should accomplish enough to justify their continuance if 
they were found to be painful, or even exceedingly irksome. Patients 
under my observation have generally complained very much of the pain 
and discomfort attending this position of extreme flexion of the arm 
and forearm, first employed by Velpeau for fractures of the clavicle. 
Moreover, I do not think the fragments are generally displaced; and if 
they were, and the final union were to be accomplished solely by liga- 
ment, I think the usefulness of the arm would not be at all impaired. 
Such, at least, has been my experience in the two cases above recorded, 
and in both of which no bony union occurred. 

In the graver forms of the accident, where other bones about the 
shoulder are broken or dislocated, which, as we have seen, constitute 
the larger proportion of the whole number, the treatment must gener- 
ally have little or no regard to this particular injury. 



CHAPTER XX. 

FRACTURES OF THE HUMERUS. 

It is not sufficient to consider fractures of this bone as occurring 
through the shaft and its two extremities, as some systematic writers 
have done ; since upon this simple arrangement it is impossible to base 
a natural division of their causes, symptoms, prognosis, and treatment. ' 

"We shall find it necessary to consider — 

1. Fractures of the head and anatomical neck. (Intra-capsular ; 
non-impacted and impacted.) 

2. Fractures through the tubercles. (Extra-capsular ; non-impacted 
and impacted.) 

3. Longitudinal fractures of the head and neck, or splitting off of 
the greater tubercle. 

4. Fractures of the surgical neck. (Including separations at the upper 
epiphysis.) 



222 



FRACTURES OF THE HUMERUS. 



5. Fractures through the body of the shaft. (Shaft below the surgi- 
cal neck and above the base of the condyles.) 

6. Fractures at the base of the condyles. (Including separation at 
the lower epiphysis.) 

7. Fractures at the base, complicated with fractures between the con- 
dyles, extending into the joint. 

8. Fractures or separations of the internal epicondyle. 

9. Fractures or separations of the external epicondyle. 

10. Fractures of the internal condyle. 

11. Fractures of the external condyle. 

Of 153 fractures of the humerus examined and recorded by me, 42 
occurred through the upper third, 31 through the middle third, and 80 
through the lower third. An observation which is in contrast with the 
statement made by Amesbury, and which has been repeated by Lizars, 
B. Cooper, Fergusson, Gibson, and others, that this bone is most often 
broken in its middle third. 

Of the fractures belonging to the upper third, 5 were supposed to be 
epiphyseal separations, one was probably a fracture at or near the ana- 
tomical neck, with impaction and splitting of the tubercles, one was a 
fracture of the greater tubercle alone, and 35 were fractures at or near 
the surgical neck. 

Of the fractures belonging to the lower third, 15 were through the 
internal condyle and epicondyle, 19 through the external condyle, 17 
were at the base of the condyles, 6 through the condyles and across the 
base at the same time. One at the epiphysis, the remaining 22 being 
through the shaft, but above the base. 

Unfortunately, surgical writers have not been agreed in the use and 
application of the terms "head," "neck," "anatomical neck," and "sur- 
gical neck" of the humerus; and, as a consequence, their meaning is 
often obscure, and their teachings are sometimes contradictory and 
absurd. 1 It is necessary, therefore, that we should define them more 
precisely. 

The " head" of the humerus is that smooth, elliptical surface, covered 
by cartilage and synovial membrane, which articulates with, and is re- 
ceived into, the glenoid cavity of the scapula. 

The "anatomical" neck is the narrow line immediately encircling 
the head, and which receives the insertion of the capsular ligament. 

The " surgical " neck is that portion which commences at the lower 
margin of the tubercles, or at the point of junction between the epiphy- 
sis and the diaphysis, and which terminates at the insertion of the pec- 
toralis major and latissimus dorsi. 

The " neck " is all of that portion included between the head, and 
the insertions of the pectoralis major and latissimus dorsi; comprising 
not only the anatomical and surgical necks, but also the tubercles; which 
latter occupy the triangular space between these two. 



Boston Med. and Surg. Journ., June 24, 1858, p. 410. 



FRACTURES OF HEAD AND ANATOMICAL NECK. 223 



I 1. Fractures of the Head and Anatomical Neck. (Intracapsular ; 
Non-impacted and Impacted.) 

Causes. — The causes which have been found competent to produce 
fractures of the head and anatomical neck are, the penetration of balls 
or of other missiles directly into the joint, producing thus a compound, 
and generally comminuted, fracture of the head; and falls, or direct 
blows upon the shoulder, without penetration. 

Pathology, Results, etc. — When the fracture results from the direct 
penetration of some foreign body into the joint, it is not only a com- 
pound fracture, but the head of the bone is almost necessarily broken 
into fragments. If the patients recover, sooner or later the fragments 
have generally to be removed. 

Fractures of the anatomical neck, produced by falls upon the 
shoulder, without penetration, are, however, usually neither compound 
nor comminuted ; and they sometimes follow, with a remarkable degree 
of accuracy, the line of the insertion of the capsular ligament, being 
always, according to Robert Smith, within the inferior or outer margin 
of this insertion. He calls them, therefore, intracapsular. It is proba- 
ble, however — since, as we shall presently see, bony union is not denied 
to this fracture — that the line of separation is not always, or generally, 
perhaps, completely within the insertion of the ligament, but that it is 
in some degree extra-articular, if not extracapsular. If it is entirely 
intra-articular, no doubt union of the fragments 
can never take place ; and necrosis, with suppura- 
tion must ensue, demanding, at a period not very 
remote, an operation for the removal of the frag- 
ments, the same as in compound fractures. 

Gibson, however, thinks that the fragment occa- 
sionally remains, being gradually absorbed and 
changed in figure. He says that his museum con- 
tains three or four well-marked cases of this kind, 
in all of which the head has lost its spherical form, 
and is very much diminished, and rough and flat- 
tened next to the scapula. 1 Other cabinets are said 
to contain similar specimens. 

The displacements to which the upper fragment, 
or the head of the bone, is subject, are remarkable, 
and some of them do not seem to be satisfactorily 
explained. Frequently, indeed, its position is not 
sensibly disturbed, but at other times it is found 
impacted, or driven into the cancellous structure 
of the inferior fragment, in consequence of which 
one or both of the tubercles are frequently broken off. 

Robert Smith relates the following case as having afforded him his 
first opportunity of ascertaining by post-mortem examination the exact 
nature of this form of displacement : 



Fig. 65. 




Fracture of the anatomi- 
cal neck. 



1 Gibson, Elements of Surgery, vol. i, p. 279. 



224 FRACTURES OF THE HUMERUS. 

" A female, set. 47, was admitted into the Richmond Hospital, under 
the care of the late Dr. McDowell, for an injury to the humerus, the 
result of a fall upon the shoulder. Five years afterwards, the woman 
was again admitted, under the care of Mr. Adams, with an extracap- 
sular fracture of the neck of the femur, one month after the occurrence 
of which she died, in consequence of an attack of diarrhoea. 

" The shoulder was of course carefully examined ; the arm was 
slightly shortened, the contour of the shoulder was not as full or round 
as that of its fellow, and the acromion process was more prominent 
than natural. Upon opening the capsular ligament, the head of the 
humerus was found to have been driven into the cancellated tissue of 
the shaft, between the tuberosities, so deeply as to be below the level 
of the summit of the greater tubercle; this process had been split oif, 
and displaced outward ; it formed an obtuse angle with the outer sur- 
face of the shaft of the bone." 1 

The description is accompanied with two excellent drawings of the 
specimen, showing the distance to which the superior fragment had 
penetrated the inferior, and showing also complete union by bone. 

I believe, also, that in the following example there was a fracture at 
or near the anatomical neck, with impaction, and splitting of the tu- 
bercles : 

January 12, 1858, a young man, aged about sixteen years, fell from 
a height in a gymnasium, severely injuring his left shoulder. I saw 
him, with Dr. Boardman, soon after the accident, and found him com- 
plaining very much of the shoulder, which was some swollen and 
tender. He could not tell us how he fell, nor could we discover any 
contusions by which to determine the point where the blow was re- 
ceived. All motions of the shoulder-joint were painful; and there 
was a remarkable fulness in front of the joint, feeling like the head of 
the bone, yet not such as is usually present in a forward luxation. To 
determine this more positively, however, the limb was manipulated as 
for the reduction of a dislocation. Once during the manipulation a 
feeble but distinct crepitus was detected ; yet the position of the bone 
remained unchanged. The head was found to be in the socket, but 
the precise nature of the injury was not made out. 

Fifteen days later, when the swelling had completely subsided, a 
careful examination was again made by Dr. Boardman and myself, 
when we arrived at the conclusion that it was a fracture through the 
bicipital groove, and that the lesser tubercle was carried forwards half 
an inch or more from its fellow, w r hile the head and the greater tuber- 
cle occupied their natural positions opposite the socket. The fragment 
projecting in front presented a sharp point, and could not be con- 
founded with any swelling of the soft parts. There was a distinct 
space between the tubercles, into which the finger could be laid. No 
depression existed under the acromion process behind, but, on meas- 
urement, the head of this humerus was found to be half an inch wider 
in its antero-posterior diameter than the opposite. 

That this fracture was accompanied with impaction was rendered 

1 South, Fractures in Vicinity of Joints, pp. 191-3. 



FRACTURES OF HEAD AND ANATOMICAL NECK. 225 

certain by the repeated and careful measurements of the length of the 
humerus, which constantly showed a shortening of half an inch. 

Under these circumstances union generally takes place ; but it is 
usually accompanied with the formation of an irregular mass of osteo- 
phytes, which encircle the head like a coronet; presenting in this 
respect again a remarkable resemblance to extracapsular fractures of 
the neck of the femur. This ensheathing callus, as it may be called, 
is an outgrowth from the inferior fragment, and it sometimes incloses 
the upper fragment as the case of a watch incloses the crystal, only in 
a manner much more irregular, thus retaining it steadily in its place, 
although very little direct union has occurred. The cancellous tissue, 
nevertheless, is occasionally found united completely by a new and 
intermediate bony tissue, and at other times by a fibrous tissue, or by 
both fibrous and bony tissue. 

In some cases a perfect false joint has been formed between the 
opposing surfaces ; while in a few unfortunate examples the head not 
only refuses to unite, but by its presence, as we have already remarked, 
produces inflammation and suppuration, resulting in its final extrusion 
from the joint. 

At other times the upper fragment turns upon its own axis, and is 
found more or less tilted or completely rotated in the socket ; so that 
its cartilaginous or articulating surface rests upon the broken surface 
of the lower fragment, and its own broken surface presents toward the 
glenoid cavity. 

Robert Smith has described a specimen of this kind which he re- 
moved from the body of a woman, aged forty, who many years pre- 
vious to her death fell down a flight of stairs, and struck her shoulder 
with great violence against the edge of one of the steps. Whether 
she applied to a surgeon or not at the time of the accident, Mr. Smith 
was not able to ascertain. After death the shoulder looked somewhat 
as if there was a dislocation of the humerus into the axilla, there being 
a marked depression under the acromion process, but the shaft of the 
humerus was drawn upwards and inwards toward the coracoid process. 

When the capsular ligament was opened, the head of the bone was 
found to have been broken from the shaft through the line of the ana- 
tomical neck, and to have completely turned upon itself; and the car- 
tilaginous surface was actually driven one inch into the cancellated 
structure of the shaft, so as to split off the lesser tubercle with a por- 
tion of the greater. Only one-half of the upper fragment was thus 
impacted, the other half projecting beyond the margin of the lower 
fragment. Between the cartilaginous surface and the shaft no union 
had occurred ; but there was complete bony union between the upper 
and lower fragments, beyond the limits of the cartilage. 

The upper surface of the superior fragment rested in part against 
the inner half of the glenoid cavity and upon its inner margin, and in 
part it rested against the neck of the scapula in the direction of the 
coracoid process. 1 

1 K. Smith, op. cit., pp. 193-6. 



226 



FRACTURES OF THE HUMERUS. 



Nelaton saw a similar specimen in the possession of M. Dubled, the 
revolution of the upper fragment being complete ; but there was no 

lateral displacement, and the union 



Fig. 66. 



Fig. 67. 



f&fc. 



h 



: i, 



had been accomplished in a manner 
similar to that which is seen after 
intracapsular, impacted fractures, 
without reversion. 1 

I have also been permitted to 
examine a specimen belonging to 
the late Dr. Charles A. Pope, of 
St. Louis, Mo., which seems to 
have been broken not only through 
the line of the anatomical neck, 
but also through the surgical neck. 
Both fragments are united by bone, 
the lower fragment being carried 
in the direction of the coracoid 
process, while the upper fragment 
appears to be reversed, so that its 
articular surface is directed toward 
the shaft, and its broken surface 
articulates with the glenoid cavity. 
The history of this specimen is 
unknown. 

Reverting to the histories of the 
several cases above referred to, in 
which these extraordinary changes 
of position have taken place, it 
would seem to admit of a doubt 
whether they were the direct result 
of the accidents which broke the 
bones, or whether they ensued 
indirectly, in consequence of a 
chronic arthritis following the accident, and the constant but long- 
continued use of the arm. 

There is another theory which, in my opinion, is capable of explain- 
ing most of the phenomena usually present in these cases, and which, 
if admitted, renders the supposition of a fracture unnecessary. It is, 
that in consequence of an injury, perhaps, but not of a fracture, a 
chronic inflammation, softening and absorption has taken place, and 
that the changed position of the head is due to pressure alone, being 
acted upon by the muscles which surround the joint, and which act all 
the more vigorously because they partake also of the inflammation 
which has invaded the bone. This view of these specimens, which 
had already more than once suggested itself to me, was very strongly 
confirmed by its having occupied the mind also of Dr. Neill, of Phil- 
adelphia, and who at his own instance stated to me that he believed 
this was their true explanation. We were, at the time, examining Dr. 



ih 



Dr. Pope's Specimen. 
Front view. Side view. 



1 Neluton, Elements de Pathol. Chirur., torn, prem., p. 307. 



LONGITUDINAL FRACTURES OF HEAD AND NECK. 227 

Pope's specimen, already alluded to, and, on comparing it with a speci- 
men of dislocation and partial absorption of the head of the humerus 
contained in Dr. NeilPs museum, the points of resemblance were so 
numerous and striking that we felt compelled to doubt whether Dr. 
Pope's specimen, together with those seen by Smith and N6laton, did 
not belong to the same class with this of NeilFs. 

In a case of fracture of the " cervix humeri within the capsular liga- 
ment/' examined by Sir Astley Cooper, there was also a complete for- 
ward luxation of the head; but ligamentous union had occurred between 
the fragments. 1 I think it certain that in this case the fracture was 
not entirely within the capsule. 

\ 2. Fractures through the Tubercles. (Extracapsular; Non-impacted 

and Impacted.) 

Under this division we intend to speak of all fractures traversing the 
upper end of the humerus, and involving the tubercles; or of all those 
which occur between the anatomical neck on the one hand, and the 
epiphyseal junction, or surgical neck, on the other hand, and which 
may be more or less oblique as well as transverse. Fractures of the 
greater or lesser tubercles are of course excepted, since they are more 
properly longitudinal fractures, and do not completely traverse the 
diameter of the bone. Nor do we intend to include those fractures 
which occur at the epiphyseal junction; since being below the principal 
insertion of those muscles which are attached to the tubercles, they pre- 
sent very peculiar and distinctive features, which will demand for them 
a separate classification and consideration. 

Causes, Pathology, and Results. — Fractures through the tubercles, 
like fractures through the anatomical neck, are the results generally of 
direct blows received upon the shoulder. The} 7 are not usually accom- 
panied with much lateral displacement at the point of fracture; a cir- 
cumstance which finds a partial explanation in the fact that the line of 
fracture is through the insertions of the muscles converging upon the 
tubercles, and not entirely above or below them, so that they continue 
to act nearly equally upon both fragments ; but it is also sometimes due 
in a measure to impaction : the head being forced downwards toward 
the axilla, and upon the shaft, until it is made to ride upon its inner or 
axillary wall like a cap; the compact bony tissue of the shaft penetrat- 
ing the reticular structure of the head. These fractures generally unite 
by bone; yet more or less impairment of the motions of the limb 
results from the inflammation which occurs in and about the joint, or 
from the irregular deposits of callus in the vicinity of the fracture. 

I 3. Longitudinal Fractures of the Head and Neck ; or Splitting off of the 

Greater Tubercle. 

Causes, Pathology, Symptoms, 'and Results. — Mr. Guthrie seems to 
have been the first to call attention to this peculiar injury of the 
shoulder. In a lecture delivered in November, 1833, he described four 

1 Sir A. Cooper on Dislocations, etc., p. 372. 



228 FRACTURES OF THE HUMERUS. 

cases which had come under his observation, and which he regarded as 
examples of separation of the small tuberosity, accompanied with more 
or less of the head, the fracture extending along a portion of the bicipi- 
tal groove. 1 

Robert Smith, however, believes that it was the greater and not the 
lesser tuberosity which was thus detached in the cases mentioned by 
Mr. Guthrie, since the external signs were so nearly like those which 
were present in a woman seen by himself, and in whom an autopsy en- 
abled him to verify his diagnosis. The following is the case as related 
by Mr. Smith : 

" In July, 1844, 1 was requested to examine the body of Julia Darby, 
set. 80, who had died of chronic pulmonary disease. Upon entering 
the room, the appearances of the left shoulder-joint at once attracted my 
attention, and struck me as being different from those which attend the 
more common injuries of this articulation. 

" The shoulder had lost, to a certain extent, its natural rounded 
form ; the acromion process, although unusually prominent, did not 
project as much as in cases of dislocation of the head of the humerus. 
The breadth of the articulation was greatly increased, and, upon press- 
ing beneath the acromion, an osseous tumor could be distinctly felt, 
occupying the greater part of the glenoid cavity; it formed a promi- 
nence which was perceptible through the soft parts ; it moved along 
with the shaft of the humerus, but was manifestly not the head of the 
bone. 

" A second and larger tumor, presenting the rounded form of the 
head of the humerus, lay beneath the base of, and internal to, the cora- 
coid process, and between the two the finger could be sunk into a deep 
sulcus, placed immediately below the coracoid process. The elbow 
could be brought into contact with the side, and there was no appreci- 
able alteration in the length of the arm. 

" Upon removing the soft parts, the head of the bone presented itself, 
lying partly beneath and partly internal to the coracoid process. The 
greater tuberosity, together with a very small portion of the outer part 
of the head of the bone, had been completely separated from the shaft 
of the humerus. This portion of the bone occupied the glenoid cavity, 
the head of the humerus having been drawn inwards so as to project 
upon the inner side of the coracoid process ; it was still, however, con- 
tained within the capsular ligament. 

" The fracture traversed the upper part of the bicipital groove, which, 
in consequence of the displacement which the head of the bone had 
suffered, was situated exactly below the summit of the coracoid process. 
A new and shallow socket had been formed upon the costal surface of 
the neck of the scapula, below the root of the coracoid process, and the 
inner edge of the glenoid cavity corresponded to the posterior part of 
the sulcus, which separated the head of the bone from the detached tu- 
berosity. The latter was united to the shaft only by ligament. 

" The capsule had not been injured, but was thickened and enlarged, 
and the bone had been deposited in its tissue. The injury had evi- 

1 Kobert Smith, p. 181, from Lond. Med. and Phys. Journal. 



FRACTURES THROUGH THE SURGICAL NECK. 229 

dently occurred many years before the death of the patient, but the 
history connected with it could not be precisely ascertained." 1 

Mr. Smith relates one other case, in the living subject, which he 
saw in connection Avith Mr. Adams, at the Richmond Hospital, and he 
adds that " numerous " other living examples have fallen under his 
observation. 

Sir Astley Cooper has also published the particulars of a case of 
fracture of the greater tubercle, which was communicated to him by 
Mr. Herbert Mayo. 2 

The following I believe also to have been an example of this rare 
accident : 

John Hill, set. 78, fell upon the sidewalk, striking upon his right 
shoulder. The physician to whom he was sent thought the humerus 
was dislocated, and directed him to the Buffalo Hospital of the Sisters 
of Charity, but he did not apply for admission until eight days after, 
Oct. 14, 1857, when Dr. Boardman and myself examined the limb 
carefully. 

Although we placed him under the influence of chloroform, the 
diagnosis was not satisfactorily made out. We inclined, however, to 
the opinion that it was a fracture of the greater tubercle. The antero- 
posterior diameter of the upper end of the bone was greatly increased ; 
there was occasional distinct crepitus, but the limb was not shortened. 

Subsequently, the examinations were repeated many times, and the 
depression between the fragments becoming more palpable, the diag- 
nosis was at length confirmed. 

No treatment was adopted, except confinement in bed, and stimu- 
lating embrocations. Two months after the accident he still remained 
an inmate of the hospital, his shoulder being quite stiff, and the pro- 
jection continuing in front. 

Dr. J. J. Charles, demonstrator of anatomy, Queen's College, Belfast, 
has reported a case with great care, which he believes to have been an 
example of this rare accident, and in which opinion I am disposed to 
concur. The man was 30 years old, and it is supposed that the middle 
of the head of the humerus was struck by the pole of a tram car. Dr. 
Charles examined the patient fourteen months after the receipt of the 
injury; the breadth of the head of the humerus was greatly increased, 
there was a broad sulcus in the situation of the bicipital groove, and 
the humerus was shortened half an inch. The motions of his arm were 
very much limited, especially in abduction. 3 

Mr. Robert Smith thinks that when the displacement is considerable, 
the fragments generally unite by ligament, rather than by bone. 

I 4. Fractures through the Surgical Neck. (Including Separations 
at the Upper Epiphysis.) 

I have already defined the "surgical neck" as all of that narrow 
portion commencing at the upper epiphysis and terminating at the 

1 Robert Smith, op. cit., p. 178. 

2 Sir A. Cooper, on Dislocations and Fractures of the Joints. Edited by B. 
Cooper. American edition, p. 384. 

3 J. J. Charles, British Med. Journ.,Sept. 26, 1874. 



230 



FRACTURES OF THE HUMERUS. 



Fig. 68. 



insertion of the pectoralis major and latissimus dorsi. It seems proper, 
therefore, that we should include under this division both fractures 
and separations occurring at the epiphysis, especially since, owing to 
their anatomical relations, they are subject to the same displacements 
as fractures occurring half an inch or one inch lower down ; the 
capsular muscles, with the exception of the teres minor, having no 
more influence over the lower fragment when a separation occurs at 
the epiphysis, than when a separation occurs at any other point of the 
surgical neck. 

Separation of the Upper Epiphysis. — A brief description of the plan 
of development of the humerus will enable the reader better to under- 
stand the occasional separation of the epiphyses, both at the upper and 
lower ends of the bone. 

The humerus is originally formed from seven cartilaginous centres, 
namely, one for the shaft, one for the head, one for the greater tuberosity, 
one for each epicondyle, and two for the lower, artic- 
ulating end of the bone. At birth the shaft is ossi- 
fied in nearly its whole length. Between the first 
and fourth years ossification commences in the 
several centres composing the upper end of the 
bone, and they coalesce by the end of the fifth year, 
so as to form a single epiphysis, which finally 
unites with the shaft at about the twentieth year. 
At the lower end of the bone, ossification com- 
mences in the radial portion of the articular surface 
at the end of two years, in the trochlear portion at 
twelve years, in the internal epicondyle at the fifth 
year, and in the external epicondyle at the thirteenth 
or fourteenth. At the sixteenth or seventeenth year 
all the centres are joined to each other, and to the 
shaft, except the inner epicondyle, which does not 
unite by bone until about the eighteenth year. It 
will be observed, therefore, that although ossifica- 
tion commences in the upper epiphysis first, it is the 
last to form bony union with the shaft. 

The following is a brief account of all the cases 
of separation at the upper epiphysis which have 
come under my notice. 
0^P Case 1.— In 1855, Mike Bovin, set. 13 months, 

fell sideways from his cradle, causing some injury 
Humerus, with epiphyses, to his arm near the shoulder. He was taken to an 
(From Gray.) empiric, who called it a sprain, and applied lini- 

ments. Three weeks after the accident he was 
brought to me, and I found the arm hanging beside the body, with 
little or no power on the part of the child to move it. There was a 
slight depression below the acromion process, and considerable tender- 
ness about the joint; but the shoulder was not swollen, nor had it been 
at any time. The line of the axis of the bone, as it hung by the side, 
was directed a little in front of the socket. 

On moving the elbow backwards and forwards, the upper end of the 



FRACTURES THROUGH THE SURGICAL XECK. 231 

shaft moved in the opposite directions with great freedom, and could 
be distinctly felt under the skin and muscles. This motion was accom- 
panied with a slight sound, or sensation, a sensation not like the grating 
of broken bone, but much less rough. There was no shortening of the 
limb. When the elbow was carried a little forwards upon the chest, 
the fragments seemed to be restored to complete coaptation ; and of 
this I judged by the restoration of the line of the axis of the shaft to 
the centre of the socket, and by the complete disappearance of the de- 
pression under the point of the acromion process. 

I applied suitable dressings to retain the arm in this position ; but 
five months after the injury was received the fragments had not united, 
and the child was still unable to lift the arm, although the forearm and 
hand retained their usual strength and freedom of motion. The same 
crepitus could occasionally be felt in the shoulder, and the same preter- 
natural mobility. The shoulder was at this time neither swollen nor 
tender. 

Case 2. — Samuel Robuck, set. 13, fell through a hatchway, July 
9th, 1868, striking on his shoulder. He saw a regular physician 
within five hours after the injury was received, who said that the arm 
was dislocated; and on the following day, under the influence of chlo- 
roform, he tried to reduce it. The doctor thought he had succeeded, 
and he then applied bandages to keep it in place. At the end of two 
weeks the doctor declined, for reasons which are not known, to have 
any further care of the case, and the patient consulted Dr. Yoss, at the 
Dispensary. Dr. Yoss detected the nature of the case, and sent him to 
me to confirm his diagnosis. I found the upper end of the lower frag- 
ment projecting in front, and not united. The arm was shortened half an 
inch. I have not seen the patient since, and do not know the result. 

Case 3. — Joseph Snellbach, set. 16, fell backwards down a flight of 
steps, striking upon his back and arm near the shoulder, May 10th, 
1868, causing a separation of the upper epiphysis of the left humerus. 

Dr. , of this city, now deceased, saw the patient within half an 

hour, and supposing that he had suffered a dislocation of the head of the 
humerus, he attempted to effect reduction with his heel in the axilla, 
and without anaesthetics. On the following day I found him in Ward 
1 6 at Bellevue. The house-surgeons were divided in opinion as to its 
character, some at first believing it to be a dislocation ; others, with 
myself, recognized it to be an epiphyseal separation. 

All efforts at replacement proving ineffectual, splints were applied 
by my direction, and on the 15th of July the patient left the hospital 
with the fragments united, but overlapped at the point of fracture, the 
upper end of the lower fragment being in front of the upper fragment. 
The limb was shortened one inch, but its motions were free, and there 
was no reason to suppose that its utility was in any degree impaired. 

Case 4. — C. H., set. 19, living in a neighboring town, in the de- 
lirium caused by fever, fell from a third-story window, May 12th, 1868. 
Two very intelligent and experienced physicians, who were called, 
thought the boy had received a fracture of the acromion process, ac- 
companied with a dislocation of the head of the humerus, and they 
attempted to reduce it, but without success. 



232 FRACTURES OF THE HUMERUS. 

On the 2d of June following, three weeks after the receipt of the in- 
jury, I saw the patient in consultation with his physicians, and found 
a separation of the upper epiphysis of the humerus. The upper end 
of the lower fragment projected in front of the acromion process, ap- 
pearing a little above the level of the process, and covered only by the 
skin. No union had occurred between the two fragments. 

Case 5. — John Davis, set. 18, fell about eight feet, September 2d, 
1873. Of the three surgeons first called, Drs. H. and S. thought the 
boy had received a fracture ; the third believed it to be a dislocation, 
and having placed the patient under the influence of ether, attempts 
were made to reduce it. The deformity not being relieved, I was added 
to the consultation. I found the shoulder a good deal swollen. The 
upper end of the lower fragment could be felt distinctly in front of the 
acromion process. At first, the surgeons informed me, the broken end 
seemed just under the skin and almost ready to be thrust through, but 
the extension had made it retire somewhat. The end felt rough and 
serrated. While making extension I was able to detect a slight crep- 
itus or click. Employing Dugas's test, I found the elbow would rest 
upon the front of the chest. In short, the diagnosis was complete, and 
Dr. S., having taken charge of the case, applied one long splint, and a 
sling under the wrist, but not under the elbow. The fragments have 
united with very little deformity. 1 

This case was subsequently seen by Dr. Moore at one of my Bellevue 
clinics, by whom my diagnosis was fully confirmed. 

Robert Smith and Sir Astley Cooper both speak of it as a frequent 
accident in early life, but the recorded cases are very few. The case 
mentioned by Mr. Smith has been given very much at length, and, as 
a characteristic example, deserves to be repeated : 

"During the early part of last year, a boy, eight years of age, was 
admitted to the Richmond Hospital, under the care of Dr. McDowell. 
About a week previous to his admission he had fallen upon the shoul- 
der, and at once lost the power of using his arm. 

"It was at first sight evident that there did not exist any luxation 
of the head of the humerus, and it was equally obvious that the case 
was not an example of any of the ordinary fractures to which the neck 
of the bone is liable. There was no diminution of the natural rotun- 
dity of the shoulder, nor any unusual prominence of the acromion 
process ; the head of the bone could be distinctly felt in the glenoid 
cavity, and it remained motionless when the arm was rotated ; there 
was very little separation of the elbow from the side, but it was di- 
rected slightly backwards. 

"About three-quarters of an inch below the coracoid process there 
existed a remarkable and abrupt projection, manifestly formed by the 
upper extremity of the shaft of the humerus, every motion imparted 
to which it followed. Its superior surface, which could be distinctly 
felt, was slightly convex, and its margin had nothing of the sharpness 
which the edge of a recently broken bone presents in ordinary fractures. 

"When this projecting portion of the bone was pushed outwards, so 

1 The Medical Record, May 1, 1874. 



FRACTURES THROUGH THE SURGICAL NECK. 



233 



as to bring it in contact with the under surface of the head of the 
humerus (previously fixed as far as it was possible to do so), a crepitus 
was produced by rotating the shaft of the bone. It did not, however, 
resemble the ordinary crepitus of -fracture, but it would be extremely 
difficult, by any description, to convey a clear idea of what the differ- 
ence consisted in. 

"From a careful consideration of the symptoms and appearances 
abovementioned (taking into account also the age of the patient), the 
diagnosis was formed, that the injury consisted in a separation of the 
superior epiphysis of the humerus from the shaft of the bone. Va- 
rious mechanical contrivances were employed in this case, but all 
proved ineffectual in maintaining the fragments in their proper rela- 
tive position." 1 

Sir Astley Cooper has also briefly described one example, which oc- 
curred in a child ten years of age. 2 

Prof. E. M. Moore, of Rochester, in a paper read before the Ameri- 
can Medical Association, in 1874, and published in the Transactions 
for that year, has called attention to what he considers the true condi- 
tion of the separated fragments in most of these cases, and to the proper 
remedy. He observes that the displacement is not usually complete ; 
but that the upper end of the lower fragment is carried inwards to the 
distance of about one-fourth of its diameter, where it is arrested, by a 
convexity of the lower fragment becoming lodged in a natural concavity 
in the upper fragment. The upper fragment now becomes tilted by the 
action of the muscles, its internal margin ascending in the glenoid cavity, 
and its outer margin descending until it is arrested by the capsule. 



Fig. 69. 



Fig. 70. 





Upper epiphysis of humerus. (From Moore.) Epiphyseal separation. (From Moore.) 

If, under these circumstances, the arm is carried forwards and upwards 
to the perpendicular line, the upper fragment or epiphysis will remain 



Robert Smith, op. cit., p. 201. 



2 Sir A. Cooper, op. cit., p. 382. 



16 



234 



FRACTURES OF THE HUMERUS. 



fixed, being held fast by the capsule inserted into the outer and pos- 
terior margin of the head, while the lower fragment or diaphysis, aided 
by the natural action of the muscles, will move outwards and resume 
its original position. 

The correctness of this opinion he has verified by having in this 
manner effected the reduction with great ease, in three cases which have 
come under his observation. The patients were respectively six, four- 
teen, and sixteen years of age. 

In the first case the reduction was effected on the fourteenth day ; in 
the second case, on the second day ; and in the third, on the seventeenth 
day. In both of the latter, ineffectual attempts had been already 
made to reduce what was supposed to be a dislocation. 

In order to maintain the reduction, it was only found necessary to 
bring the arm down while in a state of moderate extension, and to 
secure it beside the body with a Swinburne extension splint. Any of 
the forms of dressing applicable to a fracture of the surgical neck would 
probably prove equally efficient. 

The observations made by Professor Moore seem to me exceedingly 
valuable ; yet I do not think it always happens that the separation is 
incomplete, nor does Professor Moore say that it is, but only that was 
the condition in all the cases seen by him. 

In Cases 4 and 5, reported by myself, the upper end of the lower 
fragment was above the level of the coracoid process, and seemed to be 
directly beneath the skin. These were probably examples of complete 
separation; but the remaining three presented the symptoms described 
as characteristic of the partial separation in Professor Moore's paper ; 

the projection was less marked, and on a 
level with the coracoid process, or a little 
below it. 

In all of my cases the upper end of the 
lower fragment could be felt, not sharp or 
pointed, as in most examples of fracture of 
the surgical neck, but somewhat irregularly 
transverse, and when covered with the skin 
and muscle, might be easily mistaken, by 
the inexperienced, for the head of the bone. 
True Fracture at the Surgical Neck. — It 
seems necessary, in order to a full under- 
standing of the varying aspects under which 
this accident occurs, and in order to the 
establishment of the diagnosis, prognosis, 
and treatment, to relate a few illustrative 
examples. 

Case 1. Simple fracture, never displaced; 
union without deformity. — Alex. Balentine, 
set. 62; admitted to the Buffalo Hospital of 
the Sisters of Charity, December 19, 1851. He had fallen upon the 
sidewalk, striking upon his right arm. Dr. Johnson, of Buffalo, had 
reduced the fracture, and applied appropriate dressings. No union of 
the fragments had yet occurred ; but as the surfaces were in apposition, 



Fig. 71. 




Fracture of the surgical neck of the 
humerus. (From Gray.) 



FRACTURES THROUGH THE SURGICAL NECK. 235 

it was only after considerable manipulation, and not until we bent the 
forearm upon the arm, and rotated the humerus by means of the fore- 
arm, that the crepitus became distinct, and gave unequivocal evidence 
of the existence of a fracture, and of its situation. 

The treatment, after admission, consisted in the application of one 
gutta percha splint, accurately moulded, and extending from above the 
shoulder to below the elbow, and encircling one-half the circumference 
of the arm ; the splint being secured with the usual bandages, etc. 

The result is a perfect limb. 

Case 2. Simple fracture ; union, with displacement and deformity. — 
White, of Buffalo, set. 12, fell fourteen feet, striking on the front and 
outside of the left shoulder. Dr. P., of Erie County, saw the lad within 
three hours (July 19, 1853). He was brought to me on the fourth day 
after the accident. The upper part of the arm was then very much 
swollen. I found the arm dressed as for a fracture of the middle or 
lower third of the humerus. It was shortened one inch. The elbow 
was inclined backwards, and there was a remarkable projection in front 
of the joint, feeling like the head of the bone. The hand and arm 
were powerless. I suspected a dislocation of the head of the humerus 
forwards; and, having administered chloroform, I attempted its reduc- 
tion with my heel in the axilla. While making extension, I felt a 
sudden sensation like the slipping of the bone into its socket, but on 
examination I found the projection continued as before. I then re- 
peated the effort, with precisely the same result. 

I now applied an arm-sling, and directed leeches and cold evapora- 
ting lotions. 

On the 25th, five days after the accident, it was examined by Drs. 
Mixer, McGregor, Joseph Smith, with myself. We still believed it. 
was a dislocation, and, having administered chloroform, we again at- 
tempted its reduction. The same slipping sensation was produced as 
before, and the deformity was repeatedly made to disappear; but, on 
suspending the extension, it as often reappeared. 

The character of the accident was now made apparent, and we pro- 
ceeded at once to apply the splint and bandages suitable for a fracture 
of the surgical neck of the humerus, namely, a gutta percha splint, ex- 
tending, on the outside, from the top of the shoulder to below the elbow, 
with an arm and body roller secured with flour paste. 

On the 31st, twelve days after the accident, Dr. Wilcox, Marine Sur- 
geon at Buffalo, saw the arm with me. The fragments were displaced 
the same as when I first saw it, and the same as when no apparatus was 
applied. We examined it again carefully, and attempted to make the 
fragments remain in place, but we were unable to do so, except while 
holding them and making extension. 

August 9 (twenty-first day). I removed all the dressings. Motion 
between the fragments had ceased, but the projection and shortening 
remained as before; now, also, the irregular projections of the fractured 
bones were more distinctly felt. The dressings were never reapplied. 
Three months later no change had occurred. He could carry the elbow 
forwards freely, as well as backwards, the motions of the shoulder-joint 
being unimpaired. 



236 FRACTURES OF THE HUMERUS. 

Case 3. Simple fracture, with displacement; resulting in deformity and 
non-union. — L. B., of Lockport, set. 43, was thrown from his horse in 
February, 1854, striking upon his right elbow. 

Dr. Maxwell, an experienced surgeon of Lockport, examined and 
dressed the fracture. Dr. Fassett, was present and assisted at a subse- 
quent dressing. Three surgeons who examined the arm before Dr. M., 
called it a dislocation. . 

Twelve weeks after the accident, Mr. B. called upon me. The right 
arm was shortened one inch ; the elbow hung off slightly from the body ; 
the upper end of the lower fragment was distinctly felt in front of the 
shoulder-joint, under the clavicle, feeling very much like the head of 
the bone. The fragments were not united, but they could be seized 
easily, and made to move separately and freely. He stated to me that 
he was subject to rheumatism, and especially in the shoulder and arm 
of the side injured. He wished to know whether it could not be " reset." 

Two years after, I found the bone still ununited. He was, however, 
able to write with that hand, having first lifted his arm with the other 
hand and laid it upon the table. 

Case 4. Simple fracture, probably 'impacted ; resulting in deformity. — 
Wm. A., of Buffalo, set. 15, fell backwards, June 4, 1855, striking on 
his back and left shoulder. Dr. L. saw it immediately, and, regarding 
it as a dislocation, attempted its reduction. He subsequently repeated 
the attempt. I saw the patient with Dr. L. on the tenth day. The 
arm was shortened one inch and a half. The fragments were displaced 
forwards, projecting in front of and a little below the joint. As in 
Case 3, it might easily be mistaken for the head of the bone ; but the 
difficulty of diagnosis had been very much lessened by the subsidence 
.of the swelling. There was no motion between the fragments ; nor 
could the deformity, by any manipulation or extension, be made to dis- 
appear. It was probably impacted. 

March 23, 1856, nearly ten months after the accident, I found the 
fragments remaining as when I first examined the limb, and the arm 
shortened one inch and a half. The elbow hung a very little back from 
the line of the body. The upper end of the lower fragment was lifted 
to within one inch of the head of the humerus ; the upper fragment 
having its head in the socket, with its lower end downwards and for- 
wards. The arm was, however, in every respect as useful as before it 
was broken. It was equally strong, and he could raise his arm as high 
and move it in every direction as freely as he could the other. 

Causes. — Epiphyseal separations belong almost exclusively to the 
periods of youth and childhood, but true fractures at the surgical neck 
occur most often in adult life; with the exception of one girl and two 
lads, aged, respectively, eleven, twelve, and fifteen years, all of the ex- 
amples of this latter accident recorded by me (35) occurred in adults, 
and the average age is about forty-three years ; yet Sir A. Cooper de- 
clares these fractures to be most common in infancy, while Malgaigne 
has never seen a case in a person under fifty-three years. 

Both epiphyseal separations and fractures at this point are occasioned, 
in most cases, by direct blows or falls upon the shoulder. Of thirty- 
one examples in which I find the cause recorded, twenty-two were from 



FRACTURES THROUGH THE SURGICAL XECK. 237 

direct blows, eight from indirect blows, and one from muscular action, 
as in throwing a ball. Of the eight resulting from indirect blows, one 
was from a fall upon the hand, seen by Desault, and seven were from 
falls upon the elbow, of which two were seen by Desault, and five by 
myself. 

Pathology. — I have found the fragments sensibly displaced in twelve 
cases out of seventeen ; a proportion much greater than has been ob- 
served by Malgaigne, who has only seen a displacement twice in more 
than twenty cases. It is certain, however, that complete or sensible 
displacement is less common in this fracture than in most other frac- 
tures, the broken ends being retained in place, probably, by the long 
tendon of the biceps, and the long head of the triceps. 

As to the direction of the displacement, I have generally found the 
upper end of the lower fragment drawn forwards and upwards toward 
the coracoid process; in one of which examples the upper fragment 
plainly followed in the same direction. Sir Astley Cooper declares that 
with infants this direction is constant, and in museum specimens I have 
seen but one exception. In the specimens of fracture of the surgical 
neck, with also displacement of the head, belonging to Dr. Pope, this 
direction of the fragments is plainly seen, as also in a specimen belong- 
ing to Dr. Neill, of the Pennsylvania Medical College, where the lower 
fragment almost reaches the coracoid process, and in a specimen con- 
tained in one of the cabinets of the University of Pennsylvania, where 
the upper end of the lower fragment has become united by bone to the 
coracoid process. 

The only exception which I have met with is in the possession of 
Dr. Neill. In this example the two ends are tilted toward the axilla. 
I am compelled, therefore, to doubt the accuracy of Malgaigne's obser- 
vations, who thinks he has seen the lower fragment most often drawn 
toward the axilla, as well as the observations of those who think that 
the upper fragment is generally displaced outwards; yet, no doubt, 
they do sometimes assume this position. Desault has seen them both 
thrown backwards; while Dupuytren, Paletta, and others have seen 
them pushed outwards ; and I have in my cabinet the copy of a speci- 
men in which both fragments are drawn outwards, but the lower frag- 
ment is to the inner side of the upper. 

When the fracture occurs at or near the epiphysis, it is sometimes 
accompanied with impaction, of the same character as we have already 
described when speaking of fractures through the tubercles. Robert 
Smith has given, in his treatise, an engraving intended to illustrate 
the relative position of the fragments in extracapsular impacted frac- 
tures, and the line of separation very nearly corresponds to the line of 
junction of the epiphysis with the shaft. 

But in a majority of cases no impaction occurs. Dr. Charles A. 
Pope, of St. Louis, Mo., has two specimens of this kind, in which no 
union has taken place, nor is there any evidence that impaction had 
ever occurred. In one case the line of fracture commences at the junc- 
tion of the head with the shaft, and extends thence irregularly across 
to a point half an inch below the greater tuberosity. In the second 



238 FRACTURES OF THE HUMERUS. 

specimen the fracture commences at the same point, and terminates 
three-quarters of an inch below the greater tuberosity. In relation to 
these bones, Dr. Pope remarks : " These are not cases of detachment 
of the epiphyses, as the bones are evidently those of adults, aud there 
is, at their lower extremities above the condyles, no trace of an epiphy- 
seal line." 

Results. — Eight of the examples of fracture of the surgical neck 
recorded by me are known to have resulted in perfect limbs, and three 
are more or less deformed. In one of these no bony union has taken 
place after the lapse of two years or more. It is satisfactory, however, 
to know that, with the exception of this last (Case 3), all the patients 
have recovered the free and complete use of their arms. 

Symptoms, or Differential Diagnosis of Accidents about the Shoulder- 
joint. — No place could be more appropriate than this to call attention 
to the difficulty of diagnosis in the case of accidents about the shoulder- 
joint, a difficulty which surgeons have constantly recognized, and which 
has sometimes rendered diagnosis impossible. 

Let us first study the ordinary signs of a dislocation at the shoulder- 
joint, regarding, this as the type with which the other accidents are to 
be compared. 

a. Signs< of a Dislocation. ( Cause, generally a fall upon the elbow or 
hand, yet not very unfreqnently a direct blow.) 

1. Preternatural immobility. 
2.. Absence of crepitus. 

3. When the bone is brought to> its place, it will usually remain 
without the employment of force. 

These three are common signs, which apply to any other joint as 
well as to the shoulder. 

4. Inability to place the hand upon the opposite shoulder, or to 
have it placed there by an assistant, while at the same time the elbow 
touches the breast. This is a sign common to all of the dislocations 
of the shoulder. 1 

The following are special signs, or such as belong only to particular 
dislocations of the shoulder. 

5>. Depression under the acromion process ; always greatest under- 
neath the outer extremity, but more or less in front or behind, accord- 
ing as the dislocation may be into the axilla, forwards or backwards. 

6. Round, smooth head of the bone sometimes felt in its new situa- 
tion,.and very plainly removed from its socket; moving with the shaft. 
Absence of the head of the bone from the socket. 

7. Elbow carried outwards, and in certain cases forwards or back- 
wards) and not easily pressed to the side of the body. 

8. Arm shortened in the dislocation forwards, and slightly length- 
ened or its length not changed, when in the axilla. 

b. Signs of a Fracture of the Neck of the Scapula. (Cause, generally 
a direct blow ; exceedingly rare.) 

1 Report on a .New Principle of Diagnosis in Dislocations of the Shoulder-joint, 
by L. A. Dugas, Prof, of Surgery in the Medical College of Georgia. Trans. Amer. 
Med. Assoc, vol. x, p. 175. 



DIFFEEENTIAL DIAGNOSIS OF ACCIDENTS. 239 

1. Preternatural mobility. 

2. Crepitus, generally detected by placing the finger on the coracoid 
process, and the opposite hand upon the back of the scapula, while the 
head of the humerus is pushed outwards and rotated. 

3. When reduced, it will not remain in place. 

4. The hand may generally, but with difficulty, be placed upon the 
opposite shoulder, with the elbow resting upon the front of the chest. 

5. Depression under the acromion process, but not so marked as in 
dislocation. 

6. Head of the bone may be felt in the axilla, but less distinctly than 
in dislocation. Never much forwards or backwards. Head of the bone 
moves with the shaft. Head of the bone not to be felt under the acro- 
mion process, although it has not left its socket. 

7. Elbow carried a little outwards, but not so much as in dislocation. 
Easily brought against the side of the body. 

8. Arm lengthened. 

9. The coracoid process carried a little toward the sternum, and 
downwards. 

10. Pressing upon the coracoid process, it is found to be movable, 
and it is also observed that it obeys the motions of the arm. 

c. Signs of a Fracture of the Lower or Anterior Lip of the Glenoid 
Cavity. Not yet fully determined. 

d. Signs of Fracture of the Anatomical Neck of the Humerus. Intra- 
capsular. (Cause, a direct blow; generally opening to the joint, but 
not always.) 

1. Mobility not increased, nor diminished. 

2. Crepitus, generally discovered by pressing up the head of the 
bone into its socket and rotating; or, when the tubercles are also 
broken, by grasping the tubercles and rotating the arm. 

3. Fragments not generally displaced. 

4. The hand can be placed easily upon the opposite shoulder, with 
the elbow against the front of the chest. 

5. Very slight, if any, depression under the acromion process. 

6. Head of the bone generally in its socket, but not felt so distinctly 
as before the fracture. 

7. Elbow falls easily against the side of the body, or is easily placed 
there. 

8. Arm not lengthened, nor appreciably shortened, unless the head 
be driven so much into the body as to separate the tubercles. 

9. In this latter case there are present also the signs of fracture of 
the tubercles. 

e. Signs of Fracture of the Humerus through the Tubercles. Extra- 
capsular. (Cause, direct blows.) 

1. Generally, there is neither marked mobility nor immobility, 
except what immobility may be due to a contusion of the muscles. 

2. Crepitus, discovered, but not so easily as in intracapsular frac- 
tures, by rotating the arm while the tubercles are grasped firmly. 

3. If displacement exists, the fragments are not always easily kept 
in place when once reduced. 



210 FRACTURES OF THE HUMERUS. 

4. The hand can be placed upon the opposite shoulder, with the 
elbow against the front of the chest. 

5. No depression under the acromion process. 

6. Head of the bone in its socket, and moving with the shaft, when, 
as is usually the case, it is impacted. 

7. Elbow hangs against the side of the body. 

8. Arm shortened when impacted, but not much. 

The signs which characterize this accident are more obscure than 
in either of the other shoulder accidents. They are mostly nega- 
tive, and will not generally be determined positively except in the 
autopsy. 

f. Signs of a Longitudinal Fracture of the Head and Neck, or splitting 
off of the Greater Tubercle. (Cause, direct blow upon the front of the 
shoulder.) 

1. Mobility of the limb natural. 

2. Crepitus ; elicited especially by grasping the tubercles and rotat- 
ing the arm, or by carrying it up and back and then rotating. 

3. When reduced, the fragments will not remain in place. 

4. The hand can be placed upon the opposite shoulder, while the 
elbow rests against the front of the chest. 

5. Some depression under the acromion process. 

6. A smooth bony projection directly underneath the coracoid pro- 
cess, or close upon its inner or outer side, moving with the shaft. The 
head of the bone cannot be felt in the socket, yet the space under the 
acromion is not entirely unoccupied. 

7. Generally, but not always, the elbow hangs against the side. 
Sometimes it inclines a little backwards. It can always be easily 
brought to the side. 

8. Arm generally neither lengthened nor shortened. 

9. A remarkable increase in the antero-posterior diameter of the 
upper end of the bone. 

10. A deep vertical sulcus between the tubercles, corresponding with 
the upper part of the bicipital groove. 

g. Signs of a Fracture through the Surgical Neck. (Cause, generally 
direct blows, but in old people frequently caused by a fall upon the 
elbow.) 

1. Preternatural mobility often, but not constantly, present. 

2. Crepitus, produced easily when there is no impaction, or when 
the displacement is not complete, but with difficulty when impaction 
exists or the displacement is complete. 

3. When once the fragments have been displaced, it is exceedingly 
difficult ever afterward to maintain them in place. 

4. The hand can be easily placed upon the opposite shoulder, while 
the elbow rests against the front of the chest. 

5. A slight depression below the acromion, not immediately under- 
neath its extremity, but an inch or more below. 

6. Head of the bone in the socket, and moving with the shaft when 
impacted, but not moving with the shaft when not impacted. The 
upper end of the lower fragment being often felt distinctly pressing 



FRACTURES OF THE ANATOMICAL NECK. 241 

upwards toward the coracoid process; its broken extremity being 
easily distinguished by fts irregularity from the head of the bone. 

7. Elbow hanging against the side when the fragments are not dis- 
placed, but away from the side when displacement exists. 

8. Length of arm unchanged unless the fragments are impacted or 
overlapped ; or both fragments are much tilted inwards. If the frag- 
ments are completely displaced, the arm is shortened. 

h. Signs of a Separation at the Epiphysis. (Cause, direct blows.) 

1. Preternatural immobility. 

2. Feeble crepitus; less rough than the crepitus produced when 
broken bones are rubbed against each other. 

3. Fragments replaced are not easily maintained in place, unless the 
reduction has been effected by Moore's method. 

4. Same as in preceding variety of fracture. 

5. The depression is not immediately under the acromion, yet higher 
than in most fractures of the surgical neck, perhaps one inch below 
the acromion process. 

6. Head of the bone in its socket, and not moving with the shaft. 
Upper end of lower fragment projecting in front, when displacement 
exists, and feeling less sharp and angular than in case of a broken 
bone ; indeed, being slightly convex and rather smooth, it may easily 
be mistaken for the head of the bone. 

7. Same as preceding variety. 

8. Length of arm not changed unless the fragments are overlapped, 
or both fragments are tilted upon each other. When the fragments 
are overlapped, the arm is shortened. 

9. This accident is peculiar to the young. It can seldom occur after 
the twentieth year. 

There are other accidents about the shoulder-joint, such as a patho- 
logical partial luxation of the humerus, dislocation of the tendon of the 
biceps, etc., which might possibly he confounded with fractures, but the 
consideration of which I shall reserve for another time. 

Treatment. — I have already spoken of the treatment of fractures of 
the neck of the scapula, and my remarks will now be confined to frac- 
tures of the upper end of the humerus. 

Fractures of the Anatomical Neck; Intracapsular. — As has already 
been stated, these are generally compound fractures, and, from the ex- 
tent of the injury, often demand resection, or amputation of the entire 
arm. If an effort is made to save the arm, splints will not be applied, 
and the treatment will have little or no reference to the existence of a 
fracture; it will be directed only to the reduction or prevention of the 
inflammation, etc. 

Simple fracture of the anatomical neck, if not entirely within the 
capsule, without any external wound communicating with the joint, and 
accompanied, as it is sometimes, with impaction, may unite, or the 
upper fragment may become incased in the lower. 

It is not proper in such cases to employ great violence for the purpose 
of detecting crepitus, lest the fragments should become displaced; and 
if the arm should be found to be a little shortened, it must not be ex- 



242 FRACTURES OF THE HUMERUS. 

tended, with a view to overcoming the shortening, since upon the im- 
paction probably depend, in a great measure, the chances of union. 

The elbow and forearm may be suspended in a sling, while the arm 
is gently supported against the side, merely to insure quietude. No 
splints are necessary or useful. 

Treatment of Fractures through the Tubercles {Extracapsular) ; Non- 
impacted and Impacted. — In these cases, also, the fragments being sel- 
dom displaced, very little if any mechanical treatment is demanded. 
A sling is all that is usually required. If, however, on account of dis- 
placement of the fragment, a splint is thought necessary, it must be 
applied in the manner hereafter to be directed in cases of fractures of 
the surgical neck. 

If impaction, with shortening, exists, the same remarks are applica- 
ble here as in intracapsular impacted fractures, namely, that we ought 
not to rotate the limb much, nor violently, in order to discover crepi- 
tus, nor make extension with the view of overcoming the shortening, 
since the fragments unite more promptly and certainly when the im- 
paction remains, and its continuance in no way damages the usefulness 
of the limb. 

Treatment of Longitudinal Fracture of the Head and Neck, or of a 
Separation of the Greater Tubercle. — In the only instance which I have 
recognized as a fracture of the greater tubercle, and already referred to, 
the displacement was moderate, and could not be overcome either by 
change of position or by pressure with extension. The patient was 
therefore merely laid upon his back in bed. No dressings of any kind 
were employed, and the fragments seemed to unite promptly, and with 
no increase in the displacement. 

If the displacement is originally more considerable, attempts ought 
still to be made to reduce the fragments, by extension and abduction 
of the arm, with direct pressure; yet they will not generally prove 
completely successful, nor will it be found easy to retain them when 
reduced. 

Mr. Mayo treated a fracture of this character, which occurred in a 
man of sixty years of age, with a figure-of-8 bandage, and a sling, with 
a lathe splint on the other side of the humerus, the upper part of which 
was made to bear on the fragments, by uniting the upper part of the 
circular arm roller to the figure-of-8 bandage. "The fracture united 
favorably," he says, but we presume that he does not mean to affirm 
that it united without any degree of displacement; a result which prob- 
ably ought never to be expected. Mr. Mayo adds, however, that "for 
a long time the patient had some difficulty in carrying the arm back- 
wards." 1 

Treatment of Fractures of the Surgical Neck, including Separations at 
the Epiphysis. — We have already considered the value of Moore's 
method of reduction in cases of incomplete epiphyseal separations of 
the upper end of the humerus; but the reduction having been accom- 
plished, I see no reason to suppose that the indications of treatment can 

1 B. Cooper's edition of Sir A. Cooper on Dislocations, etc., American edition, p. 
835. 



TREATMENT OF FRACTURES OF SURGICAL NECK. 243 

essentially vary in separations at the epiphysis from those in true frac- 
tures through any part of the surgical neck, since the relative action of 
the muscles remains the same, and the direction of the displacement is 
generally the same. My remarks, therefore, upon this point may be 
considered as equally applicable to fractures and epiphysary separa- 
tions. 

In a considerable proportion of these cases not much displacement of 
either fragment takes place, and consequently we have only to apply 
such, moderate retentive means as will insure quiet. Indeed, under 
such circumstances we might not hesitate to adopt the posture treat- 
ment practiced by Dupuytren in two cases, both of which terminated 
favorably. The treatment consisted in placing the arm, semi-flexed, 
on a pillow, the pillow being arranged so as to form a pyramid, the 
summit of which was lodged in the axilla, while the elbow was secured 
to the side of the body by a bandage. 1 

Unhappily, however, as we have seen, this condition is not always 
present; the most frequent form of displacement being that in which 
the lower fragment is drawn upwards and inwards, or toward the cora- 
coid process. 

In such cases it will require, often, no little perseverance and skill 
to effect reduction, if it is not found to be actually impossible, and still 
more to retain the bones in place when once reduced. Indeed, it is 
proper to say that a complete reduction is seldom accomplished and 
permanently maintained, owing, probably, to the advantageous action 
of the muscles which tend to produce the displacement, and in part 
also to the difficulty of applying any apparatus or dressing which shall 
act efficiently upon the fragments. 

Sir Astley Cooper recommends for this accident a couple of splints, 
to be placed one in front of and one behind the shoulder, an axillary 
pad, a clavicular bandage, and a sling; the sling being made to sus- 
pend only the wrist and not the elbow, since he had observed that 
when the elbow was lifted the upper end of the shaft was inclined to 
fall forwards. 

Mr. Tyrrell informed Mr. Cooper that in a similar case he had found 
the bone best maintained in its natural position by its being raised and 
supported at right angles with the side, by a rectangular splint, a part 
of which rested against the side, while the arm reposed upon the other 
part; and until he had made use of this plan, he could not succeed in 
removing the deformity, or in keeping the bone in its place. 

The following is the plan which I have myself generally pre- 
ferred : 

Two splints are prepared, made of felt, gutta percha or leather. The 
latter is the most economical, generally most easily obtained, and an- 
swers its purpose as well as either of the others. The leather to be 
employed, should be sole leather, of medium thickness and hemlock 
tanned. (See General Treatment of Fractures, Chapter V.) 

1 Dupuytren on Bones, Sydenham edition, p. 99. 



244 



FRACTURES OF THE HUMERUS. 



The "long" splint must be long enough to extend from the tip of 

the acromion process 



Fig. 72. 



Fig. 73. 



Fio. 74. 



Plan of author's long 
leather arm splint. 



Long leather splint 
closed at top, and in 
shape. 



to a point just above 
the external condyle. 
The form of the 
splint, before it is 
moulded, is repre- 
sented in the accom- 
panying woodcut, 
short splint. Fig. 72. It is then 
to be bevelled or 
thinned along its edges by shaving 
a thin ribbon from the margins on 
the side which is to be laid against 
the arm ; a few holes are to be 
made with a brad-awl on the mar- 
gins of the V-shaped section at 
the upper end. Having soaked 
the splint in water, until it is ren- 
dered slightly flexible, it is rolled 
up from its two sides until it has the natural curve of the circumfer- 
ence of the arm. If it is wet too much it will yield under the pressure 
of the bandages, and this is not desirable. It ought to be straight, or 
nearly so, in its longitudinal axis, except at the top, where it embraces 
the end of the shoulder; and it should be inflexible when applied, the 
splint touching the arm firmly only over the head and tuberosities, and 
along the lower portion of the humerus. The V-shaped section at the 
top of the splint is then closed with strong linen, or shoemaker's thread ; 
and in order to give it a more regular curve, and to render it smooth, 
it may be hammered. 

Some of the splints which surgeons prepare, in imitation of this gen- 
eral plan, extend too far upon the shoulder, and are liable to be dis- 
turbed in motions of the neck or of the arm. It is only necessary that 
the splint should embrace the shoulder sufficiently to prevent its slid- 
ing down. The splint will now be completed by inclosing it in a loose 
flannel sack, stitched on the outside. If the arm is swollen and tender, 
or the skin very delicate, a thin sheet of cotton wadding should be laid 
between the cover and splint. 

The "short" splint made of leather, also — binder's board will answer 
equally well — carefully trimmed, and covered with flannel cloth, must 
have sufficient length to extend from the free margin of the axilla to 
the internal condyle, taking care that it shall not touch either. The 
purpose of this splint is not to support the fragments, for it is apparent 
that it cannot extend so high, even, as the point of fracture; but it is 
solely to protect the delicate skin beneath the arm from the bandages, 
which are apt to form cords and cause excoriations. In this point of view 
it is of great importance, and cannot properly be omitted. 

The splints being laid upon the arm, and while extension and coun- 
ter-extension are maintained by assistants, for the purpose of restoring 
the fragments to position if possible, the surgeon will apply a roller, 



TREATMENT OF FRACTURES OF SURGICAL NECK. 245 

inclosing the splints, from the elbow to the axillary margin. This 
roller must be carefully stitched to the covers of both splints. A second 
roller is then carried from the top of the long splint to the opposite 
axilla, and by several successive turns the upper end of the splint and 
the shoulder are completely covered in. This is also to be made fast to 
the cover of the long splint, by stitches. Finally, a third roller is 
made to inclose both the body and the lower portion of the arm ; and 
the forearm is secured at a right angle with the arm by a sling, looped 
under the forearm. It is important that the sling shall not embrace 
the elbow, since it will, if thus applied, tend to displace the fragments 
and drive them past each other. 

The bandage or roller hitherto applied by surgeons to the hand and 
forearm, when dressing a broken humerus, is wholly unnecessary and 
often a source of annoyance. The roller inclosing the arm and splints 
will seldom give rise to serious congestion or swelling of the forearm 
and hand unless it is applied too tightly; and when swelling does occur 
it will be promptly relieved by a few hours' or days' confinement to 
the horizontal position. The most serious objection, however, to the 
roller applied to the hand and forearm, is not that it is unnecessary, but 
that it is, in most cases, injurious. It is exceeding liable to become 
disarranged, especially if the patient is permitted to move the arm at 
the elbow-joint; and in most cases it will be soon found, by its unequal 
pressure, to cause those congestions and swellings which it was designed 
to prevent. Perhaps it will be sufficient for me to say that for many 
years I have rejected this bandage altogether in all fractures of the hu- 
merus, and that no harm has ever come of the practice. 

It will be readily seen that the first roller performs the most impor- 
tant function in this dressing. The long outer splint being firm and 
unyielding, and being supported above by the projection of the head 
of the humerus, the first roller draws the upper end of the lower frag- 
ment outwards, and thus, as far as possible, accomplishes its readjust- 
ment. The upper fragment is always beyond our control. The second 
roller is not of much use, inasmuch as it soon becomes loose; and in 
any event it can only hold the top of the splint a little more firmly 
against the head of the humerus. I occasionally omit it. The third 
roller insures quietude to the arm, in the best position, namely, beside 
the body. 

When the patient is standing or sitting, the forearm needs to be sus- 
pended in the sling; but when reclining, the forearm may, if the patient 
chooses, be extended. If the entire dressing is well stitched it is not 
much liable to disarrangement, and may be worn two or three weeks 
at a time without removal; but from time to time, as the swelling sub- 
sides or the muscles atrophy, the bandages may need to be tightened 
by overstitching, or by supplementary rollers. 

I have been thus minute in my description of this dressing, because 
its value depends upon the care with which the details are carried out; 
and because, essentially, the same dressing is used by me in all fractures 
of the humerus occurring through its upper or middle thirds ; more- 
over, I do not wish to be held responsible, in any case, for bad results 
when dressings are applied in an imperfect or slovenly manner. 



246 FRACTURES OF THE HUMERUS. 

If union takes place without overlapping, of course the arm is not 
maimed by the fracture ; but even when the union occurs with consid- 
erable overlapping, the usefulness of the arm is seldom impaired. 

I 5. Shaft, below the Surgical Neck and above the Base of the 

Condyles. 

Causes. — In a record of 22 cases in which the cause of the fracture 
is stated, I find this portion of the shaft broken from direct violence 
13 times; from indirect blows, the concussion being received upon the 
elbow, 4 times; once it was a consequence of tertiary lues, once it oc- 
curred during birth, and three times in the same patient it has been 
broken from muscular action alone, each consecutive fracture occurring 
at a different point. The records of surgery furnish many examples of 
fracture of the shaft of the humerus from muscular action, as in throw- 
ing a stone or snowball ; but the most singular examples are those in 
which the bone has been broken in a trial of strength between two 
persons, by grasping the hands palm to palm, with the elbows resting 
upon a table, and twisting, when the humerus has suddenly given way 
a little above the condyles. This practice is called by the French 
" tourner poignet" the game of turning wrists. I have seen one case 
of this kind, which was under the care of Dr. Winne, and Malgaigne 
has collected five other similar cases, two of which were reported by 
Lonsdale. In L' Union Medicate is reported an example in which the 
fracture occurred on a level with the insertion of the deltoid, a little 
below the insertion of the pectoralis major and latissimus dorsi. The 
fracture seemed to be nearly transverse. 1 

The example of fracture during birth, to which I have referred, 
occurred in a healthy female child, whose parents were also healthy. 
The mother was in labor six or eight hours, but the labor was not 
severe. She was attended by a midwife, and does not know whether 
violence was employed or not. Dr. Lockwood, of Buffalo, was called 
on the third day, and found the arm broken a little below its middle, 
and moving as freely as it did at the elbow-joint ; he applied lateral 
splints with bandages, etc. I saw the child with Dr. Lockwood on 
the seventeenth day after its birth. There was then a perfect ferrule of 
ensheathing callus surrounding the fragments, and which, owing to the 
softness of the flesh, could be easily detected and defined. The frag- 
ments had been firm at least three or four days. Nearly a year after, 
I again examined the arm, and could not discover any traces of the 
accident. 

Dr. Lowenhardt has also reported a case in which the evidence was 
conclusive that the fracture was caused solely by the contractions of the 
uterus, which forced the arm against the pubes ; the arm being heard 
distinctly to snap when it was passing this point and while the hands 
of the accoucheur were not aiding in the delivery. In this case the 
humerus was broken in its upper third. 2 

1 Amer. Med Times, vol. iv, p. 153. 

2 Lowenhardt, American Journal of the Medical Sciences, January, 1841, p. 250, 
from Medicin. Zeit., Mai 6, 1840. 



SHAFT BELOW THE SURGICAL NECK. 247 

Dr. N. Fanning, of Catskill, N. Y., has reported to me the follow- 
ing as having occurred in his own practice : 

" Mrs. H., of Catskill, was delivered June 8, 1865, after a short and 
not severe labor, of a full-grown and healthy male child. The mother 
was well formed, with ample pelvis. The labor was natural, and the 
presentation the most favorable, the occiput corresponding to the left 
acetabulum; but immediately after the delivery of the head, a hand 
and a portion of the forearm of the child were felt above the pubes. 
The shoulders and body were delivered very quickly after the head, 
and during a single pain. Just as the right shoulder of the child was 
passing under the arch of the pubes, I heard a snap, not unlike that 
caused by the breaking of a pipe-stem, which I soon found, as I sus- 
pected, to be caused by the fracture of the right os humeri of the child 
in its upper third." The bone united with some deformity. 

Dr. Fanning is of the opinion that, in this case, the contraction of 
the uterus, occurring while the arm of the child occupied some unusual 
position, was the cause of the fracture. It was certainly not due to 
any force applied by Dr. Fanning himself. 

Seat and Direction of the Fracture. — The seat of the fracture is more 
often below than above the middle of the bone; thus, I have found the 
fracture fourteen times near the middle, and the same number of times 
below the middle third, but only seven times above the middle third. 
The observations of Norris, who found four fractures of the shaft 
above the middle, and nine below, correspond with my own j 1 but M. 
Gueretin, in the same number of fractures, found nine above the mid- 
dle and four below. 2 

The line of fracture is generally oblique, but more often transverse 
than in fractures of the clavicle, femur, or tibia. 

Displacement. — The direction of the displacement depends, no doubt, 
sometimes upon the precise point of the fracture and upon the action 
of the muscles operating upon the two fragments ; thus, if the fracture 
takes place just above the insertion of the deltoid, the lower fragment 
is liable to be drawn upwards and outwards, in the direction of its 
fibres, while the upper fragment is carried toward the origin of the 
pectoralis major, etc. ; but, in a great majority of cases, the influence 
of these muscles is more than counterbalanced by the direction of the 
force, and by the direction of the fracture. Practically, therefore, it is 
seldom of much importance to determine the exact point of fracture, 
as to whether it is just above or below the insertion of a particular 
muscle ; nor, indeed, is it generally very easy to ascertain this point 
with much precision. 

The amount of displacement varies considerably in different persons 
and in fractures at different points, but it will average about three- 
quarters of an inch. When the fracture is produced by muscular 
action alone, it is generally transverse, and displacement seldom occurs. 
Such was the fact in every instance where my own patient broke the 
arm three times consecutively at different points; and union was 

1 Norris, Am. Journ. of Med. Sci., January, 1842, vol. xix, p. 28. 

2 Gueretin, Presse Medicale, vol. i, p. 45. 



248 FRACTURES OF THE HUMERUS. 

speedily accomplished, and with no deformity. Dupuytren, however, 
saw a case which constituted an exception to this general rule. The 
fragments became completely separated, and were so movable that 
union could not be effected, and he was compelled, after three months, 
to resort to resection. 

Results. — In twenty-three examples, the average shortening is about 
one-quarter of an inch ; but of these, thirteen are not shortened at all, 
so that the average of shortening in the remaining ten is three-quarters 
of an inch ; the amount of overlapping varying from one-quarter of 
an inch to one inch and a quarter. 

In forty-five examples, not including gunshot fractures, I have three 
times seen the humerus refuse to unite by bone ; once when the fracture 
was in the lower third of the shaft. This was an oblique, compound 
fracture, and no union had taken place at the end of five months. The 
man was intemperate, but in pretty good health. 1 In the second case, 
the fracture had occurred a little below the middle of the bone, and it 
was simple. Five months after the accident this patient consulted me, 
when I found the elbow anchylosed, the forearm being fixed at right 
angles with the arm. 2 Neither of these patients had been under my 
care previously, but I learned that an intelligent Canadian surgeon 
had treated one of them, and the other had been seen and treated by 
several surgeons. 

In the third case, a lad, five years of age, received a fracture about 
three or four inches above the elbow-joint, by the passage across the 
limb of a heavy army wagon. The arm was dressed with splints, and 
in about five weeks several fragments of necrosed bone were removed 
by Dr. Pope, of St. Louis, and the splints were again applied. Ten 
months from the date of the injury, Dr. Brinton, of Philadelphia, 
operated by perforation, and reapplied splints. When the splints were 
removed, the limb was straight and apparently firm, but the bond of 
union gradually gave way, and when he came under my charge in No- 
vember, 1864, more than two years after the accident, the arm was bent 
at an angle of 45°, and the union was fibrous only. Under my advice 
all restraint and dressings were removed, and he was sent into the 
country to improve his general health, with the understanding that I 
would operate at some future day. Subsequently, on the 14th of April, 
1867, 1 resected the bone at the seat of fracture, securing the fragments 
with wire, and supporting the arm with a gutta percha splint. The 
result was a perfect bony union, and a very useful arm. 

In two other cases the elbow remained somewhat stiff a long time 
after the splints were removed; in one case complete freedom of motion 
was not restored at the end of fifteen years. 

Generally, however, the motions of the elbow-joint have been very 
soon restored after the removal of the splints and sling. 

I ought to mention that, not unfrequently, fractures of the shaft of 
the humerus, and especially where they are occasioned by direct blows, 
are followed by great swelling, and sometimes by abscesses. In one 
instance, the fracture having taken place within the insertion of the 

- 1 Report on Deformities, etc., Case 33. 2 Ibid., Case 21. 



SHAFT BELOW THE SURGICAL NECK. 



249 



deltoid muscle, the sharp extremity of the lower fragment was made to 
penetrate the flesh, causing an abscess, and finally tetanus, of which my 
patient soon died. 

The following remarks of Malgaigne are too pertinent to be omitted 
this connection : " When there is great obliquity, with overlapping, 



Fig. 75. 





Lonsdale's extension appa- 



in 

or a fracture with splintering, or a multiple frac- 
ture, a certain amount of deformity is inevitable, 
and the formation of callus demands one or two 
weeks more. With the inflammation comes also 
the danger of suppuration, and later, a rigidity of 
the articulations difficult to dissipate. In short, 
we must not forget that of all fractures, those of 
the humerus are most liable to fail of consolida- 
tion." 

On the other hand, we shall find, in the case 
of this bone, as in all others, some remarkable 
exceptions, where, although the fracture may be 
compound, and badly comminuted, yet the limb 
has been saved and made useful. 

Treatment. — In the treatment of fractures of 
that portion of the shaft of the humerus now 
under consideration, we shall do best to adopt 
essentially the same plan which I have rec- 
ommended for fractures of the surgical neck. 

In proportion as the fracture occurs at a lower ratus.— a. crutch, b. shaft. 
point of the humerus, however, will it be neces- c ; ™?° w f st ; ?■ Hook for 

r -1,11 Tii n attachment of bandage, op- 

sary to extend the long splint downwards, m p0S ite which is a crossbar for 
the direction of the elbow; so that, while in the same purpose, 
fractures of the surgical neck and upper half of 

the shaft it may not be necessary to extend the splint quite as low 
as the external condyle, in the case of fractures in the lower half of 
the shaft it will be necessary to include the condyles with the splints, 
and sometimes it may be necessary to employ the gutta percha angular 
splint, w T hich will be recommended hereafter in fractures involving the 
elbow-joint. It is in these latter cases, also, that we shall find, some- 
times, the plaster of Paris dressing, including the forearm, arm, and 
shoulder, giving the most satisfactory results. Whenever the splints 
are made to touch or include the condyles, very great care must be 
taken to protect them from pressure. 

Other surgeons have sought to make permanent extension in these 
and certain other fractures of the humerus, by various contrivances. 
Mr. Lonsdale constructed an instrument which might be lengthened 
or shortened to suit the case ; it was made of steel, and was worked 
with a screw operating upon cogs in a sliding bar; resembling, in some 
respects, the arm portion of Jarvis's adjuster. In the second London 
edition of a series of plates illustrating the action of the muscles in 
producing displacement in fractures, by S. W. Hind, is a drawing of 
an apparatus invented by the author for the same purpose, which is 
very simple, and in some respects more complete than Lonsdale's, and 
which may be easily adapted to almost any form of arm-splint. In- 

17 



250 



FRACTUEES OF THE HUMERUS. 



deed, nothing more is necessary than to attach to the ordinary long 
splint a movable crutch. 

Dr. Henry A. Martin, of Boston, has invented a splint, also for the 
purpose of making extension in fractures of the humerus, the counter- 
extension being made, by adhesive plasters, from the side of the chest. 



Fig. 76. 



Fig. 77. 




H. A. Martin's extension in fractures of the humerus. 



Clark's extension in fractures of the 
neck of the humerus. 



The apparatus is elongated by a ratchet operating upon two steel bars, 
which are thus made to move upon each other. 

In my opinion, and in the opinion of nearly all practical surgeons 
who have written upon this subject, it is impossible by these or any 
other similar contrivances to make extension in fractures of the hu- 
merus. The axilla can never be made a proper point of support for 
permanent counter-extension ; and Dr. Martin's method, while it avoids 
the dangers of axillary pressure, cannot prove efficient. The adhesive 
plasters must inevitably fail to retain their places when even a mod- 
erate amount of traction is continuously made upon them. 

Dr. E. A. Clark, of the St. Louis City Hospital, has proposed to 
accomplish the extension, in fractures of the head and surgical neck, 
by suspending a weight from the elbow. He reports one case success- 
fully treated by this method. When the patient is in the recumbent 
posture, the weight must be suspended over a pulley. No doubt this 
is the only method by which really effective extension can ever be 



SHAFT BELOW THE SURGICAL NECK. 251 

made in fractures of the humerus ; and there may be, perhaps, ex- 
amples of fractures of the neck of the humerus in which the fragments 
overlap persistently, where it will be proper to resort to this novel ex- 
pedient. When fractures occur above the deltoid, the overlapping is 
often excessive, and there is not much danger of their being forcibly 
separated by the extension ; but in fractures below this, Dr. Clark's 
method would expose to the danger of separation and non-union of 
the fragments. In the case of fractures of the neck, no splints are 
used by Dr. Clark ; yet as a means of holding the lower fragment out, 
a single outside splint might be useful. 

In reference to those forms of apparatus which are intended to press 
upon the axillary margins, it ought to be stated here, since we have 
omitted to speak of it in connection with fractures of the surgical neck, 
that in all fractures of the upper half or third of the humerus, includ- 
ing fractures of the surgical neck, they must prove not only useless, 
but they must actually tend to defeat their own purpose. They are 
intended to replace the fragments ; but by their pressure upon the pec- 
toralis major and latissimus dorsi, which compose the free margins of 
the axillary space, they must inevitably cause the separation of the 
fragments. 

Malgaigne, when speaking of the apparatus of Lonsdale, remarks : 
" But the surgeon should never lose sight of the fact that permanent 
extension is a resource always dangerous, often useless, and which 
demands in its application much caution and watchful ness." 

The following example will illustrate the practical difficulty of em- 
ploying permanent extension in fractures of the humerus : 

A laborer, aged thirty, was admitted into the Buffalo Hospital of 
the Sisters of Charity, on the second day of October, 1853, with a 
simple oblique fracture of the humerus, which had occurred three days 
before. The fracture was situated within the insertion of the deltoid, 
and, having been produced by the rolling of a log upon the arm, the 
whole limb was much swollen. The night following his admission, 
in a fit of delirium tremens, he removed all of the dressings. When I 
visited the wards in the morning, I found the fragments displaced and 
the muscles contracting violently. The ordinary dressings were applied, 
and continued until the fifth day, when, as the delirium had not ceased, 
and the muscles continued to contract with great violence, it was de- 
termined to attempt permanent extension. For this purpose we lifted 
the elbow upwards and outwards, to relax the deltoid, and then, having 
made extension with the forearm placed at a right angle with the arm, 
we fitted carefully a large gutta-percha splint to the forearm, arm, 
axilla, and side, in such a manner that when the splint was secured to 
these several parts, the arm could not fall to the side of the body 
completely, and in proportion as it did fall downwards, it would make 
extension upon the arm. This splint was well padded, and secured in 
place by rollers. 

On the sixth day the delirium had ceased, and never returned. The 
dressings were well in place, and seemed to accomplish the indication 
we had in view; but, on the seventh day, although he had kept very 
quiet, everything was disarranged, and the whole had to be readjusted. 



252 FRACTURES OF THE HUMERUS. 

On the eighth and ninth the same thing occurred. During this time 
we had varied the dressings, position, etc., each day, to meet, if possible, 
the difficulties ; but it was at length deemed unwise to pursue the 
attempt any farther, and we returned to the use of the ordinary splints, 
laying the arm against the side of the body. The union was finally 
completed without either overlapping or angular displacement. 

Something may always be accomplished, when the patient is walking 
about, by allowing the elbow to escape from the sling, so that its weight 
shall make constant traction upon the lower fragment ; and the plan 
which I suggested some years since, of treating certain cases of delayed 
union of the humerus, namely, extending the arm at £ull length by the 
side of the body, so that the lower fragment shall receive the whole 
weight of the forearm and hand, might occasionally prove valuable in 
recent fractures where the tendency to override was very great. In 
three instances, I have already put this plan sufficiently to the test to 
determine its safety and utility. 

The precise plan, and my reasons for its adoption in certain cases of 
delayed union, were set forth in the following paper, read before the 
Buffalo City Medical Association, and published in the Buffalo Medical 
Journal for August, 1854. 

" I have observed that non-union results more frequently after frac- 
tures of the shaft of the humerus, than after fractures of the shaft of 
any other bone. 

u Comparing the humerus with the femur, between which, above all 
others, the circumstances of form, situation, etc., are most nearly par- 
allel, and in both of which non-union is said to be relatively frequent, 
I find that of forty -nine fractures of the humerus, four occurred through 
the surgical neck, twelve through the condyles, and twenty-nine through 
the shaft. In one of the twenty-nine the patient survived the accident 
only a few days. In four of the remaining twenty-eight union had not 
occurred after the lapse of six months, and in many more it was delayed 
beyond the usual time. Two of the four were simple fractures, and 
occurred near the middle of the humerus ; the third was compound, 
and occurred near the middle also ; the fourth was compound, and 
occurred near the condyles. 

"This analysis supplies us, therefore, with four cases of non-union, 
from a table of twenty-eight cases of fractures through the shaft. . 

"Of eighty -seven fractures of the femur, twenty occurred through 
the neck, one through the trochanter major, and one through the con- 
dyles. The remaining sixty-five occurred through the shaft, and gen- 
erally near the middle, and not in one case was the union delayed be- 
yond six months. 

"To make the comparison more complete, I must add that of the 
twenty-eight fractures of the shaft of the humerus, six were compound ; 
and of the sixty-five fractures of the shaft of the femur, six were either 
compound, comminuted, or both compound and comminuted. The six 
compound fractures of the shaft of the humerus furnished two cases of 
non-union. The six cases of either compound or comminuted or com- 
pound and comminuted fractures of the femur, furnished no case of 
non-union. 



SHAFT BELOW THE SURGICAL NECK. 253 

"I beg to suggest to the Society what seems to me to be the true ex- 
planation of these facts. 

"It is the universal practice, so far as I know, in dressing fractures 
of the humerus, to place the forearm at a right angle with the arm. 
Within a few days, and generally, I think, within a few hours, after 
the arm and forearm are placed in this position, a rigidity of the mus- 
cles and other structures has ensued, and to sisch a degree that if the 
splints and sling are completely removed, the elbow will remain flexed 
and firm ; nor will it be easy to straighten it. A temporary false an- 
chylosis has occurred, and instead of -motion mt the elbow-joint, when 
the forearm is attempted to be straightened upon the arm, there is only 
motion at the seat of fracture. It will thus happen tlaat every upward 
and downward movement of the forearm will inflict motion upon the 
fracture ; and inasmuch as the elbow has become the pivot, the motion 
at the upper end of the lower fragment will be the greater in propor- 
tion to the distance of the fracture from the elbow-joint. 

" No doubt it is intended that the dressings shall prevent all motion 
of the forearm upon the arm ; but I fear that they cannot always be 
made to do this. I believe it is never done when the dressing is made 
without angular splints, nor is it by any means certain that it will be 
accomplished when such splints are used. The weight of the forearm 
is such, when placed at a right angle with the arm., and incumbered 
with splints and bandages, that even when supported by a sling, it 
settles heavily forwards, and compels the arm-dressings to loosen them- 
selves from the arm in front of the point of fracture, and to indent 
themselves in the skin and flesh behind. By these means the upper 
end of the lower fragment is tilted forwards. If the forearm should 
continue to drag upon the sling, nothing but a permanent forward dis- 
placement w^ould probably result. The bones might unite, yet with a 
deformity. 

" But the weight of the forearm under these circumstances is not uni- 
form, nor do I see how it can be made so. It is to the sling that we 
must trust mainly to accomplish this important indication. But you 
have all noticed that the tension or relaxation of the slmg depends upon 
the attitude of the body, whether standing or sitting ; upon the erec- 
tion or inclination of the head; upon the motions of the shoulders; 
and in no inconsiderable degree upon the actions of respiration. Nor 
does the patient himself cease to add to these conditions by lifting the 
forearm with his opposite hand whenever provoked to it by a sense of 
fatigue. 

" This difficulty of maintaining quiet apposition of the fragments 
while the arm is in this position, at whatever point it may be broken, 
becomes more and more serious as we depart from the elbow-joint, and 
would be at its maximum at the upper end of the humerus, were it not 
that here a mass of muscles, investing and adhering to the bone, in 
some measure obviates the difficulty. Its true maximum is, therefore, 
near the middle, where there is less muscular investment, and where, 
on the one hand, the fracture is sufficiently remote from the pivot or 
fulcrum to have the motion of the upper end of the lower fragment 
multiplied through a long arm, while on the other hand, it is sufficiently 



254 FRACTURES OF THE HUMERUS. 

near the armpit and shoulder to prevent the upper portion of the splint 
and arm -dressings from obtaining a secure grasp upon the lower end of 
the upper fragment. 

" It must not be overlooked that the motion of which we speak be- 
longs exclusively to the lower fragment, and that it is always in the 
same plane forwards and backwards, but especially that, it is not a 
motion upon the fracture as upon a pivot, but a motion of one fragment 
to and from its fellow. This circumstance I regard as important to a 
right appreciation of the difficulty. Motion alone, I am fully con- 
vinced, does not so often prevent union as surgeons have generally be- 
lieved. It is exceedingly rare to see a case of non-union of the clavicle. 
Of forty-seven cases of fracture of the clavicle which have come under 
my observation, and in by far the greater proportion of which consid- 
erable overlapping and consequent deformity ensued, only one has re- 
sulted in non-union, and in this instance no treatment whatever was 
practiced, but from the time of the accident the patient continued to 
labor in the fields, and hold the plough as if nothing had occurred. I 
have, therefore, seen no case of non-union of the clavicle where a sur- 
geon has treated the accident. Indeed, what is most pertinent and re- 
markable, its union is more speedy, usually, than that of any other 
bone in the body of the same size. Yet to prevent motion of the frag- 
ments in a case of fractured clavicle with complete separation and dis- 
placement, except where the fracture is near one of the extremities of 
the bone, I have always found wholly impracticable. Whatever band- 
age or apparatus has been applied, I have still seen always that the 
fragments would move freely upon each other at each act of inspiration 
and expiration, and at almost every motion of the head, body, or upper 
extremities. It is probable, gentlemen, that you have made the same 
observation. 

" From this and many similar facts I have been led to suspect, for a 
long time, that motion has had less to do with non-union than was 
generally belie ved. 

" I find, however, no difficulty in reconciling this suspicion with my 
doctrine in reference to the case in question ; and it is precisely because, 
as I have already explained, the motion, in case of a fractured humerus, 
dressed in the usual manner, is peculiar. 

"In a fracture of the clavicle through its middle third (its usual 
situation), the motion is upon the point of the fracture as upon a pivot; 
although, therefore, the motion is almost incessant, it does not essen- 
tially, if at all, disturb the adhesive process. The same is true in 
nearly all other fractures. The fragments move only upon themselves, 
and not to and from each other. I know of no complete exception 
but in the case now under consideration. 

" Aside from any speculation, the facts are easily verified by a per- 
sonal examination of the patients during the first or second week of 
treatment, or at any time before union has occurred, both in fractures 
of the humerus and clavicle. The latter is always sufficiently exposed 
to permit you to see what occurs; and as soon as the swelling has a 
little subsided in the former case, you will have no difficulty in feeling 
the motion outside of the dressings, or, perhaps, in introducing the 



SHAFT BELOW THE SURGICAL NECK. 255 

finger under the dressings sufficiently far to reach the point of fracture. 
I believe you will not fail to recognize the difference in the motion 
between the two cases. Such, gentlemen, is the explanation which I 
wish to offer for the relative frequency of this very serious accident — 
non-union of the humerus. 

" I know of no other circumstance or condition in which this bone 
is peculiar, and which, therefore, might be invoked as an explanation. 
Overlapping of the bones, the cause assigned by some writers, is not 
sufficient, since it is not peculiar. The same occurs much oftener, and 
to a much greater extent, in fractures of the femur, and equally as 
often in fractures of the clavicle, yet in neither case are these results so 
frequent. Nor can it be due to the action of the deltoid muscle, or of 
any other particular muscles about the arm, whether the fracture be 
below or above their insertions, since similar muscles, with similar at- 
tachments, on the femur and on the clavicle, tending always powerfully 
to the separation of the fragments, occasion deformity, but they seldom 
prevent union. 

" If I am correct in my views, we shall be able sometimes to con- 
summate union of a fractured humerus where it is delayed, by straight- 
ening the forearm upon the arm, and confining them to this position. 
A straight splint, extending from the top of the shoulder to the hand, 
constructed from some firm material, and made fast with rollers, will 
secure the requisite immobility to the fracture. The weight of the 
forearm and hand will only tend to keep the fragments in place, and 
if the splint and bandages are sufficiently tight, the motion occasioned 
by swinging the hand and forearm will be conveyed almost entirely to 
the shoulder-joint. Very little motion, indeed, can in this posture be 
communicated to the fragments, and what little is thus communicated 
is a motion, as experience has elsewhere shown, not disturbing or per- 
nicious, but a motion only upon the ends of the fragments, as upon a 
pivot. 

" I do not fail to notice that this position has serious objections, and 
that it is liable to inconveniences which must always, probably, pre- 
vent its being adopted as the usual plan of treatment for fractured arms. 
It is more inconvenient to get up and lie down, or even to sit down, 
in this position of the arm, and the hand is liable to swell. But I 
shall not be surprised to learn that experience will prove these objec- 
tions to have less weight than Ave are now disposed to give them. 
Remember, the practice is yet untried — if I except the case which I 
am about to relate, and in which case, I am free to say, these objections 
scarcely existed. The swelling of the hand was trivial, and only con- 
tinued through the first fortnight, and the patient never spoke of the 
inconvenience of getting up or sitting down, or even of lying down. 

" The following is the case to which I have just referred : ' Michael 
Mahar, laborer, set. 35, broke his left humerus just below its middle,. 
Dec. 14, 1853. The arm was dressed by a surgeon in Canada West, 
and who is well known to me as exceedingly " clever." After a few 
days from the time of the accident, " the starch bandage w T as put on as 
tight as it could be borne, and brought down on the forearm, so as to 
confine the motions of the elbow-joint." Six weeks after the injury, 



256 FRACTURES OF THE HUMERUS. 

January 29, 1854, Mahar applied to me at the hospital. No union had 
occurred. The motion between the fragments was very free, so that 
they passed each other with an audible click. There was little or no 
swelling or soreness. In short, everything indicated that union was 
not likely to occur without operative interference. The elbow was 
completely anchylosed. I explained to my students what seemed to 
me to be the cause of the delayed union, and declared to them that I 
did not intend to attempt to establish adhesive action until I had 
straightened the arm. They had just witnessed the failure of a pre- 
cisely similar case, in which I had made the attempt to bring about 
union without previously straightening the arm. 

" ' On the 6th of February, 1854, we had succeeded in making the arm 
nearly straight. I now punctured the upper end of the lower frag- 
ment with a small steel instrument, and, as well as I was able, thrust 
it between the fragments. Assisted by Dr. Board man, I then applied 
a gutta percha splint from the top of the shoulder to the fingers, mould- 
ing it carefully to the whole of the back and sides of the limb, and 
securing it firmly with a paste roller. March 4th (not quite four weeks 
after the application of the splint) we opened the dressings for the 
second time, and carefully renewed them. A slight motion was yet 
perceptible between the fragments. March 18th, we opened the dress- 
ings for the third time, and found the union complete. This was within 
less than forty days. The patient was now dismissed. On the 29th 
of April following, the bone was refractured. Mahar had been assist- 
ing to load the "tender" to a locomotive. As the train was just get- 
ting in motion, he was hanging to the tender by his sound arm, while 
another laborer seized upon his broken arm to keep himself upon the 
car, and with a violent and sudden pull wrenched him from the tender 
and reproduced the fracture. The next morning I applied the dress- 
ings as before, and did not remove them during three weeks; at the 
end of which time the union was again complete. The splint was, 
however, reapplied, and has been continued to this time — a period of 
about six weeks/ " l 

Since the date of the above paper, I have four times had oppor- 
tunities to test the value of this mode of treatment in cases of delayed 
union of the humerus, and in each case with the same favorable result. 

Measurement. — It may be well to indicate in this place by what 
method we shall best insure an accurate measurement of the arm, or 
forearm. 

In either case, the point from which the measurement can be most 
satisfactorily made above, is the posterior and inferior edge of the 
acromion process, at the most salient point of this margin, about oppo- 
site the scapuloclavicular articulation. If the arm can be straightened, 
the extremity of either of the fingers can be used as the lower fixed 
point. If the arm cannot be straightened, Ave may use as the lower 
point either condyle, or the point of the elbow. In order to get the 
point of the elbow accurately, the hands should be clasped in front of 

1 Buffalo Med. Jcurn., vol. x, pp. 14-147. 



BASE OF THE CONDYLES. 257 

the body ; and as the elbows are pressed back, a rule may be laid be- 
neath, and the measurements made from the upper surface of the rule. 

\ 6. Base of the Condyles. Syn. Supracondyloid Fracture of the 
Humerus.— Malgaigne. 

Causes. — Of 17 fractures at this point, 11 occurred in children under 
ten years of age, the youngest being two years old. 

In 11 cases the fracture had been produced by a fall, and it is pre- 
sumed that the blow was received upon the elbow ; in the remaining 
six cases the cause is not stated. I believe, therefore, that this fracture 
is generally the result of an indirect blow, inflicted upon the extremity 
of the elbow; in a few examples it has been produced by a blow 
received directly upon the point of fracture, as by the kick of a horse, 
etc., but I have never, save in a single instance, been able to trace it to 
a fall upon the hand. Dr. Shearer, U. S. A., has reported a case also, 
which seems to have occurred in the same manner. 1 



Fig. 




Fractures at the base of the condyles. (From Gray.) 

Direction of the Fracture, Displacement, and Symptoms. — I think 
this fracture is generally oblique, and its line of direction upwards and 
backwards ; in nine of the eleven cases where this point was determined, 
such has been its apparent direction, and the lower fragment has been 
found drawn up behind the upper. Once I have found the lower 
fragment in front, and once on the outside of the upper. 

Three of the 17 were compound comminuted fractures, this being 
a larger proportion of serious complications than is usually found in 
connection with fractures of long bones. 

I have never met with what I supposed to be a separation of the 
lower epiphysis; but surgical writers have occasionally spoken of this 
accident, and the late Dr. Watson, of New York, believed that he had 
seen one example in an infant not quite two years old. The limb had 
been violently wrenched by the mother, in attempting to lift her. She 

1 M. M. Shearer, Act. Asst. Surgeon, U. S. A. Boston Journ. of Chemistry, 
Feb. 1, 1870. 



258 



FRACTURES OF THE HUMERUS. 



was not seen by Dr. Watson until the fourth day, at which time the 
swelling was such that the diagnosis could not be easily made out; but 
on the ninth day Cl it was apparent that the shaft of the humerus had 
been separated from its cartilaginous expansion at the condyles, near 
the elbow." By the use of angular pasteboard splints the reduction 
was maintained, and the fragments became united after about four or 
six weeks. 1 

Dr. J. C. Reeve, of Dayton, Ohio, has recently sent me a specimen 
of epiphyseal separation, which occurred in his practice in the year 

1864. A girl, set, 10, fell a few 
feet, striking, probably, upon her 
elbow. The fracture was com- 
pound, and union not having oc- 
curred at the end of three weeks, 
the condition of the arm rendered 
amputation necessary. In this 
case a small fragment of the shaft 
came away with the epiphysis. 
Drs. Little, Voss, and Buck, of 
this city, have each reported a 
similar case. 2 

The diagnosis of a fracture at 
the base of the condyles is at- 
tended with peculiar difficulties, 
and it has occasionally been mis- 
taken for a dislocation of the 
radius and ulna backwards. Du- 
puytren says : " There is nothing 
so common as to see a fracture of the lower end of the 
humerus, immediately above the elbow-joint, mistaken 
for a dislocation backward;" and he mentions three cases 
which have come under his own observation. I have 
found an opposite error, however, by far the most fre- 
quent, namely, a dislocation of both bones backwards has been sup- 
posed to be a fracture. 

The sources of this embarrassment are found in the proximity of 
the fracture to the joint, in the rapidity with which swelling occurs, 
and in the striking similarity of the symptoms which characterize the 
two accidents. 

It will be necessary, therefore, to establish with care the differential 
diagnosis. The following are the signs of fracture : 

1. Preternatural mobility, which, owing to the rapidity of the swell- 
ing and the contraction of the muscles whose tendons are stretched over 
the projecting ends of the bones, is often soon lost, being succeeded, 
sometimes after a few hours, by a rigidity equal to that which is usually 
present in dislocations, or even greater. It is especially difficult to flex 




Dr. Reeve's case of sep- 
aration of the lower epi- 
physis of the humerus. 



Separation of 
lower epiphysis 



1 Watson, New York Journ. Med., Nov. 1853, p. 430, second series, vol. xi. 

2 Little, Voss, and Buck, New York Journ. Med., Nov. 1865, p. 133. 



BASE OF THE CONDYLES. 259 

the arm, owing to the pressure by the upper fragment into the bend of 
the elbow. 

2. Crepitus. This can usually be detected at any period if the arm 
is sufficiently extended, so as to bring the broken surfaces again into 
apposition. 

3. When the extension is sufficient, reduction is easily effected, and 
the natural length of the arm is restored; but the limb immediately 
shortens when the extension is discontinued — especially if at the same 
moment the elbow is bent. This is a very important means of diagnosis. 

4. A careful measurement, made from the point of the internal 
condyle to the acromion process, declares a positive shortening of the 
humerus. 

5. By flexing and extending the forearm upon the arm, while the 
fingers are placed upon the lower portion of the humerus, the project- 
ing fragments can be felt. Generally, the upper fragment being in 
front of the lower, and pressing down into the bend of the elbow, its 
end cannot be so easily recognized; but the upper end of the lower 
fragment can easily be made out, posteriorly, when the forearm is con- 
siderably flexed. The lower end of the upper fragment feels more 
rough, and is less wide, than in dislocations. 

6. The whole of the lower fragment is carried backwards, and with 
it the radius and ulna, producing a striking prominence of the elbow 
and olecranon process. Efforts to straighten the forearm upon the arm, 
when no extension is used, increase rather than diminish this projection. 

7. The forearm is slightly flexed upon the arm, the angle made at 
the elbow being about 25 or 30 degrees. 

8. The hand and forearm are pronated. 

9. The relations of the olecranon process with the two condyles 
remain unchanged. 

In a case of epiphyseal separation, the lower end of the upper frag- 
ment has greater breadth than in the case of a fracture at the base of 
the condyle, and the line of separation is nearer the end of the bone. 

Signs of a Dislocation of the Radius and Ulna Backwards. — 1. Pre- 
ternatural immobility. That is to say, extension and flexion are limited, 
but there is almost always present a preternatural lateral mobility. 

2. Absence of crepitus. It is in this joint especially that surgeons 
have been deceived by the chafing of the dislocated bones upon the in- 
flamed joint surfaces, and have supposed that they discovered crepitus 
when no fracture existed. The rapidity with which inflammation de- 
velops itself after dislocations of the elbow-joint, and the consequent 
abundant effusion of lymph, afford the probable explanation of this 
frequent error. 

3. When reduced, the bones are not generally disposed to become 
again displaced, even though the elbow should be flexed. 

4. The humerus is not shortened, but the olecranon process approaches 
the acromion process. 

5. There are no sharp projecting points of bone. The lower end of 
the humerus may not always be felt in the bend of the elbow; but 
when it is felt, it is found to be relatively smooth, broad, and round. 



260 FRACTURES OF THE HUMERUS. 

6. A remarkable prominence of the elbow and olecranon process, 
which prominence is sensibly diminished when an effort is made to 
straighten the forearm on the arm. 

7. Forearm flexed upon the arm to about the same degree as in frac- 
ture. 

8. Hand and forearm pronated, precisely as in fracture. 

9. Relations of the olecranon process to the condyles changed very 
greatly. 

The most constant diagnostic signs are, then, in the case of a frac- 
ture, crepitus, shortening of the humerus, projection of the sharp ends 
of the fragments, and an increase of the projection of the elbow when 
an attempt is made to straighten the arm ; and in the case of a dislo- 
cation, the absence of crepitus, humerus not shortened, while the olec- 
ranon approaches the acromion process; the smooth, round head of the 
humerus lost, or indistinctly felt in the bend of the elbow, and the pro- 
jection of the point of the elbow diminished when an attempt is made 
to straighten the forearm on the arm. 

It is proper, also, to repeat here what we have already said in rela- 
tion to the causes of this fracture. A fracture at this point is produced 
almost always by a fall upon the elbow, but a dislocation of the radius 
and ulna backwards can never be. On the other hand, a dislocation is 
produced, in most cases, by a fall upon the palm of the hand, while I 
have never known but one fracture above the condyles to be thus pro- 
duced. 

Results. — Nine times have I found the arm shortened from half an 
inch to one inch, or a little more. 

Muscular anchylosis is almost always present when the apparatus is 
first removed, and it is seldom completely dissipated until after several 
months ; but I have found more or less anchylosis at seven and nine 
months; and twice after the lapse of three years the motions of the joint 
have been very limited. A few years since, I examined the arm of a 
gentleman who was then twenty-seven years old, and who informed me 
that when he was four years old he broke the humerus just above the 
condyles. There still remained a sensible deformity at the point of 
fracture — he could not completely supine the forearm. The whole arm 
was weak, and the ulnar nerve remarkably sensitive. The ulnar side 
of the forearm, and also the ring and little fingers, were numb, and have 
been in this condition ever since the accident. I know the surgeon 
very well who had charge of this case, and I have no doubt that the 
treatment was carefully and skilfully applied. 

In June of 1850, I operated upon a lad, nine years old, by sawing 
off the projecting end of the upper fragment, whose arm had been 
broken nine months before. This fragment was lying in front of the 
lower, and the skin covering its sharp point was very thin and tender. 
There was no anchylosis at the elbow-joint, but the hand was flexed 
forcibly upon the wrist, the first phalanges of all the fingers extended, 
and the second and third flexed. Supination and pronation of the fore- 
arm were lost. The forearm and hand were almost completely para- 
lyzed, but very painful at times. The ulnar nerve could be felt lying 
across the end of the bone. 



BASE OF THE CONDYLES. 261 

In the hope that some favorable change might result to the hand by- 
relieving the pressure upon the nerve, yet with not much expectation 
of success, I exposed the bone and removed the projecting fragment. 
The nerve had to be lifted and laid aside. About one year from this 
time I found the arm in the same condition as before the operation. 

Non-union is a result not so frequent in fractures at this point as 
higher up; but Stephen Smith, of the Bellevue Hospital, New York, 
reports a case of non-union in a young man of twenty-three years. He 
was admitted to the hospital on the seventh day after the accident. 
The fracture was simple and transverse, yet at the end of four months 
he was dismissed "with perfectly free motion at the point of fracture." 1 
The failure to unite was attributed to a syphilitic taint. 

A case was tried a few years since in the Supreme Court at Brook- 
lyn, N. Y., in which, after a simple fracture at this point, the arm 
being dressed with splints and bandages, the little finger sloughed off 
in a condition of dry gangrene, and the adjacent parts of the hand 
were attacked with moist gangrene. Drs. Parker and Prince believed 
that this serious accident was the result of bandages applied too tightly 
and suffered to remain too long, while Drs. Valentine Mott, Rogers, 
Wood, Ay res, Dixon, and others, believed the gangrene might have 
been due to other causes over which the surgeon had no control. 2 

A few years ago, a similar case occurred in the town of Spencer, 
Tioga Co., N. Y. ; a boy, six years old, having broken his humerus 
just above the condyles. The fracture was oblique. The surgeon 
who was called to treat the case was an old and highly respectable 
practitioner. I am not informed of the plan of treatment any farther 
than that a roller was applied. On the eighth day, a second surgeon 
was employed, who, finding the hand cold and insensible, removed all 
of the dressings; after which the thumb and forefinger sloughed, with 
other portions of the skin and flesh of the hand and arm. The sur- 
geon who was first in attendance was prosecuted, and the case was 
tried in the Supreme Court of that county, but the jury found no cause 
of action. Dr. Hawley, of Ithaca, and the late Dr. Webster, of Geneva 
Medical College, testified that, in their opinion, the death of the fingers 
was owing to the pressure of the fragment upon the brachial artery, 
and not to the tightness of the bandages. 

Dr. Gross has also informed us of still another case of the same 
character, which occurred in Warren Co., Ky. A boy, ten years old, 
had broken his arm above the condyles, and his parents having em- 
ployed a surgeon residing at some distance, the dressings were applied, 
and directions given to send for the surgeon whenever it became neces- 
sary. The parents saw the arm swell excessively, and knew that the 
boy was suffering very much, but did not notify the surgeon until the 
tenth day, when the hand was found to be in a condition of mortifica- 
tion, and at length amputation became necessary. 

Long afterward, in the year 1851, when the boy became of age, he 

1 Smith, New York Journal of Medicine, May, 1857, p. 386, third series, vol. ii. 
* New York Medical Gazette, vol. xii, pp. 46, 80, 111. 



262 



FRACTURES OF THE HUMERUS. 



prosecuted his surgeon, but with no result to either party beyond the 
payment of their respective costs. 

While I would not deny that in all of these cases the sloughing 
might have been solely due to the tightness of the bandages, against 
which cruel and mischievous practice we cannot too loudly declaim, a 
knowledge of the anatomy of these parts, and the opinions of the very 
distinguished gentlemen who testified in defence of these surgeons, 
must compel us to admit the possibility of such accidents where the 
treatment has been skilful and faultless. 

Treatment. — The splints generally employed in this country, in frac- 
tures about the elbow-joint, are simple angular side splints, without 



Fig. 81. 



Fig. 82. 




Welch's splint. The hinges may he transferred to 
splints of different sizes. 

joints, such as those recommended by Physick: 1 angular pasteboard 
splints, felt, leather, gutta percha, etc., or angular splints with a hinge, 
such as Kirkbride's, 2 Thomas Hewson's, Day's, Rose's, Welch's, or 
Bond's. 

Kirkbride's splint, which has been used in the Pennsylvania Hos- 
pital in several instances, is composed of two pieces of board, connected 
together by a circular joint, and having eyes on the inner edge, two 
inches apart, and holes through the splint at graduated distances be- 
tween them. There is also a swivel eye, passing through the upper 
part of the splint, and riveted below. A wire is fastened to the swivel, 
and bent at right angles at its other extremity, of a size to fit the eyes 
and holes in the splint. This splint, properly supported by pads, is to 



1 Elements of Surgery, by John Syng Dorsey, Philadelphia edition, vol. i, p. 145. 

2 American Journal of the Medical Sciences, vol. xvi, p. 315. 



BASE OF THE CONDYLES. 



263 



be placed either upon the outside or inside of the arm, and secured by 
rollers. When the angle is to be changed, the wire is unhooked and 
removed to another eye, or to some of the intermediate holes upon the 
side of the splint. Dr. Kirkbride reports two cases of fracture of the 
lower part of the humerus treated by this plan, one of which resulted 
in anchylosis, but the other was much more successful. 

H. Bond, of Philadelphia, has contrived a very ingenious splint for 
the elbow-joint, and which is designed also to afford a complete support 
to the forearm. 

For myself, I generally prefer gutta percha, moulded and applied 
accurately to the limb. It should be extended beyond the elbow to 

Fig. 83. 




Bond's elbow splint. 



the wrist, so as to support the whole length of the arm, elbow, and 
forearm. Some experience in the use of wooden angular splints has 
convinced me that they cannot be very well fitted to the many inequal- 
ities <5f the limb; and neither pasteboard nor binder's board has suffi- 
cient firmness, especially in that portion which covers the joint. Angu- 
lar splints, furnished with a movable joint, possess the advantage of 
enabling us to change the angle of the limb at pleasure, and of keeping 
up some degree of motion in the articulation without disturbing the 
fracture or removing the dressings; but the crossbars of Day's and 
Rose's splints render them complicated, and are in the way of a nice 
application of the rollers; while they are all equally liable to the ob- 
jection stated against angular wooden splints without joints, viz., that 
they seldom can be made to fit accurately the many irregularities of 
the arm, elbow, and forearm. In applying the author's splint, care 
must be taken that the humeral portion is not too short, or the result 
will be an unnecessary degree of overlapping of the fragments. This 
may generally be avoided if the surgeon will first shape his material 
to the sound arm, while the whole length is underlaid with three or 
four thicknesses of woollen cloth. Welch's splints, made of a material 
possessing a slight amount of flexibility, approach more nearly the ac- 
complishment of all the indications than any other manufactured splint 



264 



FRACTURES OF THE HUMERUS. 



with which I am acquainted, but the number of cases in practice to 
which they are applicable will be found to be limited, while gntta percha 

has no limit in its application. 

Whatever material is employed, 
the splint should be first lined 
with one thickness of woollen 
cloth, or some proper substitute. 
A pretty large pledget of fine 
cotton batting ought also to be 
laid in front of the elbow-joint, 
to prevent the roller from excor- 
iating the delicate and inflamed 
skin; and great care should be 
taken to protect the bony emi- 
nences about the joint, or, rather, 
to relieve them from pressure, by 
increasing the thickness of the 
pads above and below these emi- 
nences. 

At a very early day, so early, 
indeed, as the seventh or eighth 
day, the splint should be removed, 
and, while the fragments are 
steadied, gentle, passive motion 
should be inflicted upon the joint. 
This practice should be repeated 
as often as every second or third day, in order to prevent, as far as 
possible, anchylosis. If much swelling follows the injury, it is my 
custom to open the dressings, without removing the splints, on the 
second or third day after the accident, or at any time when the symp- 
toms admonish of its necessity. Occasionally it is well to change the 
angle of the splint before reapplying it. If the angular splint with a 
movable joint is used, slight changes may be made while the splint is 
on the arm; but if the angle is much changed without removing the 
rollers, they become unequally tightened over the arm, and may do 
mischief. 

When anchylosis has actually taken place, we may more or less 
overcome the contraction of the muscles and of the ligaments by gentle, 
passive motion, or by directing the patient to swing a dumb bell or 
some other heavy weight, as first recommended by Hildanus; but we 
must bear in mind the danger of causing a refracture by too early or 
immoderate force. 




The author's elbow splint. 



I 7. Fracture at the Base of the Condyles, complicated with Fracture 
between the Condyles, extending into the Joint. 

This fracture, which is but a variety or complication of the preced- 
ing, is even more difficult of diagnosis ; and its signs, results, and 
proper treatment differ sufficiently to demand a separate consideration. 




FEACTUEE AT THE BASE OF THE CONDYLES. 265 

I have recognized the accident six times. Confined to no period 
of life, it seems to be the result of a severe blow inflicted directly 
upon the lower and back part of the humerus, 
or upon the olecranon process. Dr. Parker, of fig. ss. 

Kew York, was inclined to regard an obscure 
accident about the elbow-joint, which he saw in 
a lad sixteen years old, as a longitudinal frac- 
ture of the humerus, with separation of one 
condyle, but which had been occasioned by a 
fall upon the hand. 1 For myself, I should re- 
gard this latter circumstance as presumptive 
evidence that it was not a fracture of this char- 
acter, yet I do not mean to deny the possibility 
of its occurrence in this way. 

Its characteristic symptoms are, increased 
breadth of the lower end of the humerus, oc- 
casioned by a separation of the condyles; (lis- between, the condyles, 
placement upwards and backwards of the radius 

and ulna ; shortening of the humerus ; crepitus and mobility at the 
base of the condyles, with crepitus also between the condyles, developed 
by pressing them together ; or in case the radius and ulna are drawn 
up and back, the crepitus may be detected, after restoring these bones 
to place, by pressing upon the opposite condyles. 

Its consequences are, generally great inflammation about the joint, 
permanent deformity and bony anchylosis. An opposite result must 
be regarded as fortunate, and as an exception to the rule. 

Of the treatment we can only say that it must be chiefly directed to 
the prevention and reduction of inflammation ; at least during the first 
few days. JN^or is this inconsistent with an early reduction of the 
fragments, and moderate efforts, by splints and bandages, such as we 
have directed in case of a simple fracture at the base of the condyles, 
to keep the fragments in place. No surgeon would be justified in re- 
fusing altogether to make suitable attempts to accomplish these impor- 
tant indications ; but he must always regard them as secondary when 
compared with the importance of controlling the inflammation. 

When splints are employed, the same rules will be applicable, both 
as to their form and mode of application, as in cases of simple fracture 
above the condyles. Plaster of Paris, or some of the immovable forms 
of dressing, furnished with ample fenestra?, will sometimes be preferred. 

The following examples will more completely illustrate the character 
history, and proper treatment of these cases than any remarks or rules, 
which we can at present make. 

A woman, set, 44, fell upon the sidewalk in January, 1850, striking 
upon her right elbow. I saw her a few minutes after the accident, but 
the parts about the joint were already considerably swollen, and it was 
not without difficulty that the diagnosis was made out. The forearm 
was slightly flexed upon the arm, and pronated. On seizing the elbow 
firmly, a distinct motion w r as perceived above the condyles, and a 

1 Parker, New York Journal of Medicine, Nov. 1856, p. 391, 3d series, vol. i. 

18 









260 FRACTURES OF THE HUMERUS. 

crepitus. I could also feel, indistintly, the point of the upper frag- 
ment. While moderate extension was made upon the arm, the con- 
dyles were pressed together, when it was apparent that they had been 
separated. On removing the extension, they again separated, and the 
olecranon drew up. She was in a condition of extreme exhaustion, 
and the bones were easily placed in position. 

An angular splint was secured to the limb, and every care used to 
support the fragments completely, but gently. 

From this date uutil the conclusion of the treatment the dressings 
were removed often, and the elbow moved as much as it w r as possible 
to move it. 

Seven months after the accident, the elbow was almost completely 
anchylosed at a right angle. The fingers and wrist also, were quite 
rigid. Six years later, the anchylosis had nearly disappeared ; she 
could now flex and extend the arm almost as much as the other; the 
w T rist-joint was free, and the fingers could be flexed, but not sufficiently 
to touch the palm of the hand. The line of fracture through the base 
could be traced easily, but the humerus was not shortened. There 
was, moreover, much tenderness over the point of fracture through the 
base, and at other points. Occasionally, a slight grating was noticed 
in the radio-humeral articulation. She experienced frequent pains in 
the arm, and especially along the back and radial border of the ring 
finger. During the first year or two after the accident, the arm per- 
ished very much, but although the hand remained weak, the muscles 
were now well developed. 

A gentleman w T as struck with the tongue of a carriage with which 
a couple of horses were running. The blow was received directly upon 
the back of the left elbow. Dr. Sprague and myself removed some 
small fragments of bone, and while opening the wound for this pur- 
pose, we could see distinctly the line of fracture extending into the 
joint as well as across the bone. The condyles were not separated. 

The subsequent treatment consisted only in the use of such means 
as would best support the limb, and most successfully combat inflam- 
mation. The arm and forearm were laid upon a broad and well- 
cushioned angular splint, covered with oil-cloth, to which they were 
fastened by a few light turns of a roller. 

Twelve years after, I found the humerus shortened one inch and a 
half. During the first year, he says, there w r as no motion in the elbow- 
joint, but he can now flex and extend the forearm through about 45° ; 
when flexed to a right angle, it seems to strike a solid body like bone. 
Rotation of the forearm is completely lost, the hand being in a posi- 
tion midway betw r een supination and pronation. He suffers no pain, 
and his arm is quite strong and useful. No means have been employed 
to restore the functions of the limb but passive motion at first, and 
subsequently constant, active use of the hand and arm. 

The late Dr. Thomas Spencer, of Geneva, used to relate a case in 
which a surgeon was called to what he supposed to be a fracture of the 
lower end of the humerus, and which he treated accordingly, with 
splints, etc. On the second or third day, another surgeon was called, 



FRACTURE AT THE BASE OF THE CONDYLES. 267 

who removed the splints and bandages, and pronounced it a dislocation 
of the radius and ulna backwards ; but he was unable to reduce it. 

After some time, the first surgeon was prosecuted for having treated 
as a fracture what proved to be a dislocation. Dr. Spencer, who had 
examined the arm carefully, gave his testimony last, and at a time 
when, from the evidence, it seemed almost certain that the surgeon 
must be mulcted in heavy damages ; but he declared his belief that 
both surgeons were right, since, on measuring the breadth of the 
humerus through its two condyles, he found that the humerus of the 
injured arm was three-quarters of an inch wider than the opposite. 
His conclusion, therefore, was that the condyles had been split asunder 
and were now separated ; that the first surgeon properly reduced this 
fracture, but that when, on the second or third day, the second surgeon 
removed the splints and the dressings, a contraction of the muscles had 
taken place and the dislocation occurred, the bones of the forearm being 
drawn up between the fragments. Dr. Spencer believed this was an 
example of the variety of fractures now under consideration, but it is 
not quite certain that there was anything more than an oblique fracture 
extending into the joint, followed by a dislocation. In either case, the 
first surgeon was entitled to an acquittal, and so the jury promptly 
declared by their verdict. 

In a case of compound comminuted fracture of the character now 
under consideration, Dr. Stone, of the Bellevue Hospital, New York, 
removed the condyles and sawed off the sharp end of the humerus. 
The woman was twenty-six years old and intemperate. The operation 
was made as a substitute for amputation. No serious complications 
followed. On the ninety-sixth day the wounds were completely healed, 
and she could bend the forearm to a right angle with the arm, the 
action of the muscles having drawn up the radius and ulna against 
the lower end of the shaft of the humerus, so that the motions were 
natural and free. 1 The practice, as the result sufficiently shows, was 
eminently judicious ; and its practicability ought always to be well 
considered before resorting to the serious mutilation of amputation. 
The great principle upon which the success of resection is here based 
is the shortening of the bone, whereby the reduction may be accom- 
plished without painful tension to the muscles ; a principle which will 
demand of us hereafter a more careful consideration and a wider appli- 
cation. 

Fractures of the Condyles. 

Chaussier described that portion of the lower end of the humerus 
which articulates with the ulna as the trochlea, and that portion which 
articulates with the radius as the condyle; naming the two lateral 
projections, respectively, epitrochlea aud epicondyle. Some of the 
French writers have adopted this nomenclature, but I prefer, as being 
more familiar to my own countrymen, the terms external and internal 
condyle, to which it will be convenient to add the terms external epi- 
condyle and internal epicondyle, as indicating the extreme lateral pro- 

1 Stone, New York Journ. of Med., May, 1851, p. 302, vol. vi, 2d series. 



268 



FRACTURES OF THE HUMERUS. 



jections, which are formed from separate points of ossification, and 
which do not become united to the condyles by bone until about the 
sixteenth or eighteenth year of life. 

When, therefore, we speak of a fracture of the epicondyle, we refer 
only to a separation of the epiphysis, such as it is in early life ; or to 
its true fracture, when, at a later period, it has become united by bone. 



I 8. Fractures of the Internal Epicondyle. (Epitrochlea, Chaussier.) 

This is the fracture which Granger first described in the Edinburgh 
Medical and Surgical Journal, 1 and which he ascribed solely to muscu- 
lar action. "A distinguishing circumstance attending this fracture is 
that of its being occasioned by sudden and vio- 
fig. 86. lent muscular exertion; and it will be recollected 

that from the inner condyle those powerful mus- 
cles which constitute the bulk of the fleshy sub- 
stance of the ulnar aspect of the forearm have 
their principal origin. The way in which the 
muscles of the inner condyle are involuntarily 
thrown into such sudden and excessive action I 
take to be this : the endeavor to prevent a fall 
by stretching out the arm, and thus receiving 
the percussion from the weight of the body on 
the hand." 2 

It is a fact, perhaps of some significance in 
this connection, that most of these fractures occur 
in children, before the union of the epiphysis is 
Fracture of internal completed, when muscular contraction might 
epicondyle. more often prove adequate to its separation, and 

when the epicondyle is less prominent, and, 
therefore, less exposed to direct blows than in adult life; thus, of five 
fractures which I have distinctly recognized as fractures of the epicon- 
dyle, all, except one, occurred between the ages of two and fifteen years. 
But then it is equally true that a large majority of all the fractures of 
the internal condyle, including those which enter the articulation, as 
well as those which do not, belong to childhood and youth. I have 
seen but two exceptions in fifteen cases. Since, then, direct blows 
generally produce those fractures which penetrate the joint, no good 
reason can be shown why they should not produce fractures of the 
epicondyle. One of the exceptions to which I have referred as not 
having occurred in early life, is sufficiently rare to entitle it to especial 
notice. 

On the 16th of May, 1856, a laborer, thirty-four years of age, fell 
from an awning upon the sidewalk, dislocating the radius and ulna 
backwards; the dislocation was immediately reduced by a woman who 




1 " On a Particular Fracture of the Inner Condyle of the Humerus," by Benja- 
min Granger, Surgeon, Burton-upon-Trent. Op. cit., vol. xiv, pp. 196-201, April, 
IS 18. 

2 Ibid., p. 196. 



FRACTURES OF THE INTERNAL EPICONDYLE. 269 

came to his assistance, but when he called on me soon after, I found a 
small fragment of the inner condyle, probably the epicondyle alone, 
broken off' and quite movable under the finger. It was slightly dis- 
placed in the direction of the hand. 

I could not learn positively whether in falling he struck the elbow 
or the hand, but there was presumptive evidence that he struck the 
hand; if so, then probably the fracture was the result of muscular 
action, which is the more extraordinary as having taken place in a 
man of his age. 

It is pretty certain, however, that the theory of causation adopted by 
Granger is too exclusive. A lad was brought to me in October, 1848, 
aged eleven, who had just fallen upon his elbow, the blow having been 
received, as he affirmed, and as the ecchymosis showed pretty conclu- 
sively, directly upon the inner condyle. The fragment was quite loose, 
and crepitus was distinct. He could flex and extend the arm, and ro- 
tate the forearm, without pain or inconvenience. I am quite sure the 
fracture did not extend into the joint ; the result seemed also to confirm 
this opinion, for in three months from the time of the accident the 
motions of the elbow-joint were almost completely restored. 

Indeed, Mr. Granger has failed to establish, by any particular proofs, 
that in more than one or two of his cases the fracture was the result of 
muscular action; but, on the contrary, I am disposed to infer, from the 
violent inflammation which generally ensued in his cases, from the fre- 
quency of ecchymosis, and especially from the injury done to the ulnar 
nerve in at least three instances, that most of them were produced by 
direct blows inflicted from below in the fall upon the ground. Frac- 
tures produced by muscular action are seldom accompanied with much 
inflammation or effusion of blood, and it is much more probable that 
the ulnar nerve should have been maimed by the direct blow which 
caused the fracture, than by the displacement of the epiphysis, which 
is, as we shall presently show, almost always carried downwards, and 
oftener slightly forwards than backwards. It is only when the frag- 
ment is forced directly backwards that the ulnar nerve could be made 
to suffer; a direction which, it does not seem to me, it could ever take 
from muscular action alone. 

Direction of Displacement, Symptoms, etc. — I have seen this fragment 
displaced in the direction of the hand, or downwards, very manifestly, 
twice, and in two other examples a careful measurement showed a 
slight displacement in the same direction. The greatest displacement 
occurred in a boy fifteen years old, who was brought to me from St. 
Catharine, Canada West. He had fallen upon his arm is wrestling, 
and his surgeon found a dislocation of the bones of the elbow-joint, 
which he immediately reduced. The fracture was not at that time de- 
tected, the arm being greatly swollen. No splints were applied. It 
was three months after the accident when I saw him, at which time I 
found the internal epicondyle broken off and removed downwards 
toward the hand one inch and a quarter; and at this point it had be- 
come immovably fixed. Partial anchylosis existed at the elbow-joint, 
but pronation and supination were perfect. 

In one instance I believed the fragment to be carried about three 



270 FRACTURES OF THE HUMERUS. 

lines upwards and two backwards toward the olecranon; in each of the 
other examples the fragment has not seemed to suffer any sensible dis- 
placement. 

Granger found, also, in the five examples which came under his 
notice, the epicondyle carried toward the hand, with more or less vari- 
ation in its lateral position, so that while in some instances it touched 
the olecranon, in others it was removed an inch or more in the oppo- 
site direction. 

It is probable that, except where controlled by the force and direc- 
tion of the blow, or by some complications in the accident, the frag- 
ment, if displaced at all, always moves downwards toward the hand, 
or downwards and a little forwards, in the direction of the action of the 
principal muscles which arise from this epiphysis; and when the frac- 
ture or separation is the result of muscular action alone, this form of 
displacement seems to me to be inevitable. In addition to the mobility, 
crepitus, and generally slight displacement of the fragment, which are 
the principal signs of this fracture, it may be noticed that there is usu- 
ally some embarrassment in the motions of the elbow-joint, w T hich may 
be due in part to the swelling, and in part to the detachment of the 
point of bone from and around which most of the pronators and flexors 
of the forearm have their rise. In one instance, already quoted, that 
of the lad aged eleven years, who broke the epicondyle from a direct 
blow, the motions of pronation, with flexion, were not at all impaired, 
neither immediately nor at any subsequent period, but the fragment 
was never sensibly, or only very slightly, displaced. 

Granger has recorded another class of symptoms, to which I have 
already alluded, bis explanation of which, however, I am not prepared 
to admit. One of these cases he describes as follows: A boy, eight 
years old, fell with violence, and broke off completely the whole of the 
inner epicondyle of the right humerus. The lad said he had fallen on 
his hand. The fragment was displaced toward the hand. Severe in- 
flammation followed, but he recovered the free and entire use of the 
elbow-joint in less than three months after the accident. No splints or 
bandages were ever employed. 

From the moment of the accident, the little finger, the inner side of 
the ring finger, and the skin on the ulnar side of the hand, lost all sen- 
sation. The abductor minimi digit! and two contiguous muscles of the 
little finger were also paralyzed. This condition lasted eight or ten 
years, after which sensation and motion were gradually restored to 
these parts. As a consequence of this paralyzed condition of the ulnar 
nerve, also, successive crops of vesications, about the size of a split 
horse-bean, commenced to form on the little finger and ulnar edge of 
the hand some weeks after the accident, leaving troublesome excoria- 
tions. This eruption did not entirely cease for two or three months. 

In two other cases, Mr. Granger remarks that he has found " the 
same paralysis of the small muscles of the little finger, the same loss 
of feeling in the integuments, and the same succession of crops of vesi- 
cles on the affected parts of the hand, as is described to have occurred 
in the preceding case." 

Without intending to intimate a doubt of the accuracy of Mr. Gran- 



FRACTURES OF THE INTERNAL EPICOXDYLE. 271 

ger's statement, that such phenomena have followed in three cases out 
of the five which he has seen, I must express my belief that it was 
only a remarkable concurrence of circumstances, since the same phe- 
nomena have never been seen by myself, nor do I know that they have 
been observed by any other surgeon. 

Results. — As in all other accidents about the elbow-joint, a temporary 
rigidity is almost inevitable. The mere confinement of the arm in a 
flexed position is sufficient to determine this result without the inter- 
position of a fracture; but when inflammation occurs, more or less con- 
traction of the tendons, muscles, etc., about the joint must ensue. To 
this circumstance, therefore, added to the confinement, rather than to 
the fracture, will be due the anchylosis. If the fragment is not dis- 
placed, the fracture cannot certainly be responsible for the loss of 
motion, since it does not in any way involve the joint; and if displace- 
ment exists, its ultimate effect in diminishing the power of the muscles 
which arise from the epiphysis must be only trivial and scarcely ap- 
preciable. "We might, therefore, reasonably conclude that where the 
accident has been properly treated, permanent anchylosis would be the 
exception, and not the rule. This view of the matter seems also to be 
sustained by the recorded results. In Granger's cases, the full range 
of flexion and extension of the forearm has been finally restored, or 
with so trifling an exception as not to be observable without close 
attention, in every instance; except in the one already mentioned, which 
was originally complicated with dislocation; and even in this case the 
ultimate maiming was inconsiderable. Malgaigne, who says "it ought 
to be understood that in this accident articular rigidity is almost inevi- 
table," seems nevertheless to admit the justness of Granger's observa- 
tions as to the final result, if the proper means are employed to prevent 
it. I have myself found only once any considerable impairment of 
the motions of the joint after the lapse of a few years. 

Treatment. — This accident does not constitute an exception to the rule 
which experience has established, that small epiphyseal projections, 
when once displaced, can seldom be restored completely to, or main- 
tained in position. Granger remarks : " I have purposely avoided 
saying one word about replacing the detached condyle (epicondyle), 
and for these reasons : during the state of tumefaction of the limb, no 
means could be adopted for confining the retracted condyle in its place, 
beyond that of the relaxation of the muscles; and both before the tume- 
faction has commenced, and after it has subsided, all endeavors to re- 
place the condyle, or even to change the position of it, have failed." 
He even proceeds so far as to declare that while attention ought to be 
given to the reduction of the inflammation by appropriate means, we 
ought, nevertheless, to instruct the patient to flex and extend the arm 
daily from the moment the accident occurs until the cure is completed, 
and without any regard to the consolidation of the fragment; "the ex- 
ercise of the joint in this manner must constitute the principal occupa- 
tion of the patient for several weeks; and should it be remitted during 
the formation and consolidation of the callus, much of the benefit which 
may have been derived from this practice will be lost, and will with 
difficulty be regained." 



272 



FRACTURES OF THE HUMERUS. 



Fig. 87. 



"With only slight qualifications I would adopt the advice of Mr. 
Granger. The limb ought, at first, to be placed in a position of semi- 
flexion, so that if anchylosis should unfortunately ensue, it would be 
in the condition which would render it most serviceable, and also be- 
cause in this position the muscles which tend to displace the fragment 
would be most completely relaxed. While thus placed, an attempt 
ought to be made, by seizing the epiphysis, to restore it to position; 
and if the effort succeeds, as it certainly is not very likely to do, a com- 
press and roller ought to be so applied as to maintain it in position ; 
provided, always, that it shall not be found necessary to apply the^ 
roller so tight as to endanger the limb, or increase the inflammation. 
An angular splint would be an almost indispensable part of the apparel, 
at least with children, where this indication is in view. In no case, 
however, ought more than seven or fourteen days to elapse before all 
bandaging and splinting should be abandoned, and careful but frequent 
flexion and extension be substituted. 

In three cases seen by me, a displacement of the fragment, either for- 
wards or backwards, has occurred whenever the 
arm was flexed, and it has been necessary, there- 
fore, to treat the case with the arm in a straight 
position. These are plainly only exceptions to 
the rule. 

I 9. Fractures of the External Epicondyle. (Epi- 
condyle, Chaussier.) 

I have only mentioned this supposed fracture, 
of which some writers have spoken as a fact, in 
order that I may declare my conviction that its 
existence has never been made out. If we admit 
the possibility, that, while in a state of epiphysis 
it might, like the corresponding internal epiphy- 
sis, be separated by muscular action, we must 
yet deny its probability, since it is so exceedingly 
small ; and we must, for the same reason, be per- 
mitted to doubt whether the fact of its separation could be recognized 
in the living subject. Moreover, if a true fracture occurs at this point 
as the result of external violence, it is sufficiently plain, from an ex- 
amination of the anatomical structure, that it must more or less extend 
into the joint and involve the condyle itself. 




Fracture of external epi- 
condyle. 



§ 10. Fractures of the Internal Condyle. (Trochlea, Chaussier.) 

B. Cooper, South, Sir Astley Cooper, and others, speak of fracture 
of the internal condyle as very common, and more so than fracture of 
the external condyle; while Malgaigne. who admits its existence, has 
never met with a single living example, and regards its occurrence as 
exceedingly rare. In a record of fifteen fractures, I have found no diffi- 
culty in recognizing five as fractures of the inner condyle; five, I have 
already said, were fractures of the epicondyle, and the remainder were 




FRACTURES OF THE INTERNAL CONDYLE. 273 

undetermined, while my records furnish nineteen examples of undoubted 
fractures of the external condyle. It is probable that Sir Astley did 
not intend to make any distinction between frac- 
tures of the condyle and epicondyle, and this FlG - 
might explain somewhat his opinion of the rela- 
tive frequency of these accidents; but even reject- 
ing this important distinction, it has happened to 
me to see more examples of fracture of the outer 
condyle than of the inner. 

Causes. — It has already been stated that frac- 
tures of the internal condyle, as well as fractures 
of the epicondyle, belong almost exclusively to 
infancy and childhood, only two instances having 
come under my notice after the eighteenth year 
of life. 

I have seen no instance which could be traced 
to. any other cause than a direct blow, such as a 

„ ,. J i li ip /» i • Fracture of internal con- 

lall upon the elbow, the iorce of the concussion dyie. 

being received directly upon the condyle. 

Line of Fracture, Displacement, Symptoms. — The direction of the line 
of fracture is tolerably uniform, namely, commencing about one-quarter 
or half an inch above the epicondyle, it extends obliquely outwards 
through the olecranon and coronoid fossae, and enters the joint through 
the centre of the trochlea. 

Displacement of the lower fragment can take place only in a direc- 
tion upwards, backwards, forwards, and inwards (to the ulnar side). 
The fragment cannot be carried downwards, in the direction of the hand, 
nor outwards, in the direction of the radius, unless the radius also is 
broken or dislocated. 

The most common form of displacement is upwards and backwards, 
and perhaps at the same time a little inwards; the ulna remaining at- 
tached to the lower fragment, and following its movements. I have 
seen one instance in which the fragment was carried directly down- 
wards toward the hand, but this accident was originally complicated 
with a dislocation of the radius backwards. The dislocation was im- 
mediately reduced. Five years after, when the young man was twenty- 
three years old, I found the condyle displaced downwards and forwards 
about half an inch, so that when the forearm was extended it became 
strikingly deflected to the radial side. 

The symptoms which characterize this fracture are crepitus, almost 
always easily detected ; mobility of the fragment, discovered especially 
by seizing upon the epicondyle, or by flexing and extending the arm ; 
displacement of the smaller fragment and a projection of the olecranon 
process, this latter being very marked when the forearm is extended 
upon the arm, but almost completely disappearing when the elbow is 
bent ; projection of the lower end of the humerus in front when the 
arm is extended; the humerus shortened when measured along its ulnar 
side, from the internal epicondyle; the breadth of the humerus through 
its condyles generally increased slightly, sometimes half an inch or more; 
if the lesser fragment is carried upwards, it will also be found that 



274 FRACTURES OF THE HUMERUS. 

when the limb is extended, the forearm will be deflected to the ulnar 
side. 

Sir Astley Cooper remarks that it is frequently mistaken for a dis- 
location ; and Thomas M. Markoe, of New York, has shown that it is, 
in fact, frequently complicated with a dislocation of the head of the 
radius backwards ; indeed, he expresses a belief that this dislocation 
of the radius seldom or never occurs without a fracture of the internal 
condyle. 1 I shall refer to his views again when considering disloca- 
tions of the head of the radius. 

Results. — It is probable that in a majority of cases no permanent 
displacement exists; although the irregularity of the bony deposits 
around the base of the condyle, which generally may be easily felt, 
would lead to a contrary opinion. The fact that the lower fragment 
usually follows the motions of the olecranon, renders its replacement 
and retention comparatively easy, unless some complication exists. It 
is not from displacement, therefore, so much as from permanent mus- 
cular, and especially bony anchylosis, that serious maiming so often 
results. Under any treatment bony anchylosis will very often ensue, 
and under improper treatment it is almost inevitable. 

Treatment. — The arm must be immediately flexed to nearly or quite 
a right angle, when, without much manipulation, the fragments will 
be made to resume their place. A gutta percha, or felt, right-angled 
splint, such as I have already directed for fractures occurring just above 
the condyles, well and carefully cushioned, may now be applied, and 
secured by rollers. Suitable pads must also aid the splint and roller, 
in keeping the fragments in place. Markoe prefers keeping the fore- 
arm in a position about ten degrees short of a right angle, believing 
that in this position the ulna itself will act as a splint, and, by its sup- 
port on the uninjured portion of the trochlea, hold in its place the 
broken condyle. Very properly, also, he prefers to lay the angular 
splint, made of tin, and fitted to the arm and forearm, upon the back 
of the limb, instead of upon the front or sides. If it is upon the inside, 
it covers the broken condyle, and we are unable to know so well its 
position; if upon either side, it is apt to press injuriously upon the 
epicondyles; and if it is in front, the fragments cannot be so well ad- 
justed or supported. Upon this point, however, surgeons are not very 
Avell agreed, and no doubt more will depend upon the care with which 
the splint is applied than upon the surface against which it is laid. 

Considerable -swelling is almost certain to follow, and no surgeon 
ought to hazard the chances of vesications, ulcerations, etc., by neglect- 
ing to open or completely remove the dressings every day. Within 
seven days, and perhaps earlier, passive motion must be commenced, 
and perseveringly employed from day to day until the cure is accom- 
plished ; indeed, in a majority of cases it is better not to resume the 
use of splints after this period ; for, although at this time no bony 
union has taken place, yet the effusions have somewhat steadied the 

1 Markoe, New York Journal of Medicine, May, 1855, p. 382, second series, vol. 
xiv. 



FRACTURES OF THE EXTERNAL CONDYLE. 275 

fragments, and the clanger of displacement is lessened, while the pre- 
vention of anchylosis demands very early and continued motion. 

When the fracture is compound, or otherwise complicated, these 
simple rules will seldom be found applicable ; indeed, fractures at- 
tended with no such complications will occasionally be found difficult 
to reduce, or to maintain in position after reduction. 

1 11. Fractures of the External Condyle. 

Causes. — All the fractures (19) of the external condyle, of which I 
have a record, occurred in children under fourteen years of age, except 
one ; in which instance a woman, eighty-eight years of age, fell upon 
her elbow while intoxicated, breaking off the outer condyle. Two 
months after the accident I found the fragment displaced half an inch 
upwards, and firmly united. 

In a large majority of these cases the patients themselves have 
affirmed, and the surface of the skin has furnished conclusive evidence, 
that the fracture was produced by a direct blow, generally by a fall 
upon the elbow. 

Line of Fracture, Displacement, and Symptoms. — The direction of 
the fracture is generally such that, commencing always above and 
without the capsule, it descends obliquely and enters the joint either 
just within or through the " small head " or articulating surface upon 
which the radius is received ; or else it penetrates more deeply in its 
progress, and passing through the olecranon fossa, it enters the joint 
through the middle of the trochlea. 

In the first of these classes of examples, which I think also is the 
most common, the condyle alone is broken off, and it is liable only to 
become displaced backwards, forwards, or outwards ; generally, I have 
found it displaced a little outwards sufficiently to increase manifestly 
the breadth of the condyles, or it has been carried backwards ; once 
slightly forwards ; it is also, in some cases, carried upwards in a small 
degree, although the action of the supinators and extensors would seem 
to render a downward displacement more common. These displace- 
ments are usually not considerable, and in a few cases there is none at 
all. Whatever may be the direction or degree in which the fragment 
is moved, however, the head of the radius is found almost always to 
accompany it ; but in the case which I am about to relate, the head of 
the radius became completely separated from the condyle. 

Frederick Keaffer, set. 11, fell from a load of hay, and he is confi- 
dent that he struck the ground with the back of his elbow. Six hours 
after the accident he was brought to me by the physician who was first 
called to him. The arm was much swollen, and the external condyle 
could not be distinctly felt, but when pressure was made directly upon 
it, crepitus and motion became manifest. The head of the radius was 
at the same time dislocated backwards, and separated entirely from the 
condyle, its smooth button-like head being very prominent. It is 
difficult to conceive how a blow from behind should leave the head of 
the radius dislocated backwards, or how the radius could have sepa- 
rated from the broken condyle ; but as the examination was repeated 



276 



FRACTURES OF THE HUMERUS. 



Fig. 89. 




Fracture of the external 
condyle. 



several times, and while the patient was under the influence of ether, 
I have no doubt of the fact. Several other surgeons who were present 
concurred with me in opinion fully. 

While prosecuting the examination, I reduced 
the dislocation of the radiur, but it would not re- 
main in place a moment when pressure or support 
was removed. The lad recovered with a very 
useful arm, the motions of flexion and extension, 
with pronation and supination, after the lapse of 
a year, being nearly as complete as before the ac- 
cident, the radius remaining unreduced. 

Sometimes it will be noticed that while the por- 
tion of the condyle which is attached to the radius 
falls backwards, its upper and broken extremity 
pitches forwards; and this attitude it is especially 
prone to assume when the forearm is extended. 

It is even possible, when the fracture traverses 
the trochlea, for the ulna also to become displaced 
backwards along with the radius and the lesser 
fragment. 

Crepitus, which is usually very distinct, is most easily obtained by 
rotating the radius, or by seizing upon the condyle with the thumb 
and fingers, and moving it backwards and forwards. 

Results. — Ordinarily, this fragment unites promptly, and by the 
interposition of a bony callus ; but in four cases, I have noticed that 
either no union has occurred, or the union has been accomplished only 
through the medium of fibrous structures, and the fragment continued 
afterward to move with the radius. 

As a consequence, probably, of the displacement of the lesser frag- 
ment upwards, the forearm, when straightened, is occasionally found 
deflected to the radial side. The surgeon must not, however, confound 
the deflection which is natural and which is greater in some persons 
than in others, with the unnatural radial inclination which is occa- 
sioned sometimes by this accident. I have met with this phenomenon 
three times in children under three years of age, in one of which I 
could not discover that the condyle was carried toward the shoulder, 
but only outwards ; in each of the other cases the fragment had united 
by ligament. The following is one of the examples referred to: 

A girl, set. 3, fell and broke the external condyle of the left humerus, 
the fracture extending freely into the joint; crepitus distinct; forearm 
slightly flexed ; prone. Lesser fragment displaced outwards and a 
little backwards, carrying with it the radius. On the second day I 
was dismissed on account of the unfavorable prognosis which I gave, 
or rather because I refused to guarantee a perfect limb, and an empiric 
was employed. 

July 2, 1857, several months after the accident, the father brought 
her to me for examination. There was no anchylosis, but the lesser 
fragment had never united, unless by ligament, moving freely with 
the head of the radius. When the forearm was straightened upon the 



FRACTURES OF THE EXTERNAL CONDYLE. 277 

arm it fell strongly to the radial side, but resumed its natural relation 
again when the elbow was flexed. 

Two other examples are reported at length, in the second part of my 
Report on Deformities after Fractures, as Cases 57 and 59 of fractures 
of the humerus. 

In one other example, however, mentioned also in my report as 
Case 56, the deflection was to the opposite side. I examined the lad 
one year after the accident, he being then five years old, and I found 
the external condyle very prominent and firmly united, but not appar- 
ently displaced in any direction except outwards. The radius and 
ulna had evidently suffered a diastasis at their upper ends, but all of 
the motions of the joint were free and perfect. 

Dorsey 1 speaks of this lateral inclination as being always to the 
ulnar side, but does not indicate to what particular fracture of the 
elbow it belongs. He has also described a splint, contrived by Dr. 
Phvsick, intended to remedy the deformity in question. 

Chelius also speaks of the same deformity as occurring after fractures 
of the internal, but does not mention it in connection with fractures of 
the external condyle, that is, an inclination of the forearm to the ulnar 
side. 

In more than half of the cases of fracture of this condyle some 
degree of anchylosis has resulted, lasting at least several months. I 
have seen it remaining after a lapse of from one to twenty years, but 
generally it gradually diminishes, and, in a majority of cases, com- 
pletely disappears after a few years. 

Treatment. — I do not know that I need add much to what has already 
been said in relation to the treatment of fractures of the opposite con- 
dyle, and at the base of the condyles, since the measures applicable to 
the one are, in general, applicable to the other. 

Generally, the forearm ought to be flexed upon the arm, especially 
with a view to overcome the usual tendency in the upper end of the 
lower fragment to pitch forwards, and which form of displacement is 
greatly increased by straightening the arm. A remarkable exception 
to this rule, and one of two which I have seen, must be mentioned. 

James Crony n, aged 6, was brought to me in March, 1857, having, 
a few minutes before, fallen from a height of four or five feet to the 
ground. His father said the elbow had been broken at the same point 
two years before, and from that time had remained stiff and crooked. 
I found the external condyle broken off, and, with the head of the 
radius, carried backwards. This was the position which it occupied 
constantly, though it was easily restored and maintained in position 
when the arm was straight, but not by any possible means when the 
elbow was flexed. I dressed the arm, therefore, in an extended posi- 
tion, with a long felt splint, and the fragments remained well in place 
until a cure was accomplished. 

It is especially deserving of notice that, in the four cases in which 
I have observed bony union to fail, and the fragments to continue 
movable, the motions of the elbow T -joint have, in a very short time, 

1 Elements of Surgery, by Philip Syng Dorsey, Phila. ed., 1813, vol. i, p. 146. 



278 FRACTURES OF THE HUMERUS. 

been completely restored. If it does not prove that Granger was 
correct in his views as applied to fractures of the internal epicondyle, 
namely, that it was of little or no consequence whether the fragment 
united or not, and that the elbow-joint ought to be submitted to free 
motion from the beginning to the end of the treatment — if it does not 
absolutely prove, I say, the correctness of his views, it at least must 
abate our apprehensions of the supposed evil results of non-union in 
the case of the fracture now under consideration. 

I shall take the liberty of quoting also, with a qualified approval, 
the opinion of Dr. John C. Warren, of Boston, as stated by Dr. Norris 
in his Report on Surgery, made to the American Medical Association 
in 1848. 

"In the treatment of fractures of the condyles of the os humeri, a 
course is usually recommended which he believes to be hurtful, inas- 
much as it favors the worst consequences of the injury, namely, loss 
of motion in the joint. By this mode of treatment, the fractured piece 
becomes sufficiently fixed to create partial anchylosis; and there is so 
much pain afterwards in the proposed passive movements as to cause 
the omission of these measures until permanent stiffness takes place. 
The proper course in the management of these accidents, he conceives 
to be — 1st. To apply no splints, but in the earlier days to make use 
of the proper means to prevent inflammation. 2d. To accustom the 
patient to early and daily movements of flexion and extension. 3d. 
When the action of the joint becomes limited, to overcome the resist- 
ance by force, and repeat it daily until the tendency of the joint to 
stiffen ceases. 

" The accomplishment of this process, he adds, is so very painful 
that few patients have courage to submit to it, and few surgeons firm- 
ness to prosecute it. The consequence has been that in a great num- 
ber of cases the use of the articulation to a greater or less extent has 
been lost. The introduction of etherization, by preventing the pain, 
gives us, in the opinion of Dr. Warren, the means of overcoming the 
resistance. By its aid he has restored the motion of a considerable 
number of anchylosed elbows, and has successfully applied the same 
measures to other joints, particularly to the shoulder and knee. This 
has now become his settled practice, with the results of which he is 
entirely satisfied. The inflammation consequent upon the forced 
movements of an anchylosed joint is not to be lost sight of. By a 
reasonable abstraction of blood, and other anti-inflammatory treatment, 
he has never found it alarming." 1 

My respect for the distinguished surgeon whose opinion is here 
given does not permit me to question the correctness of his practice ; 
but I cannot avoid a belief that his language does not convey a precise 
idea of his views. If he intends to say that he would move the joint 
freely when it is suffering from acute inflammation, and when motion 
occasions great pain, I must protest against the practice as likely to 
do vastly more harm than good in any case ; but if he would move the 

1 Transactions of the American Medical Association, vol. i, p. 174. 



FRACTUKES OF THE NECK OF THE RADIUS. 279 

joint from the first, when the inflammation and swelling are trivial, 
and when it occasions only an endurable amount of pain, then his views 
are just and his practice worthy of imitation. 



CHAPTER XXI 



FRACTUKES OF THE RADIUS. 

Of one hundred and nine fractures of the radius which have been 
recorded by me, not including gunshot fractures, or fractures demand- 
ing immediate amputation, three belonged to the upper third, eight to 
the middle third, and ninety-eight to the lower third. Four were 
compound, and one hundred and five simple. Sixty-two are reported 
as occurring in males, and forty-seven in females; forty-nine as having 
occurred in the left arm, and thirty-five in the right. 

Fracture of the neck of the radius, as a simple accident, uncompli- 
cated with any other fracture or dislocation, is exceedingly rare ; yet, 
owing to the depth of the superincumbent mass of muscles, and the 
difficulty of determining, where so many bones and processes approach 
each other, precisely from what point the crepitus, if any is found, 
proceeds, surgeons have often been deceived, and they have believed 
that they were the fortunate possessors of this rare pathological treas- 
ure, when the autopsy has too soon disclosed their error. Both B. 
Cooper and Robert Smith have alluded to this difficulty, and the case 
reported by Dr. Markoe to the New York Pathological Society, and 
published in the American Medical Monthly, will serve to illustrate 
the same point ; in which case the signs of a fracture of the radius at 
its neck were such as to deceive that experienced surgeon, yet the 
autopsy disclosed the fact that it was a dislocation of the head of the 
radius forwards, with a fracture of the ulna. Indeed, its existence as 
a form of fracture was doubted by Sir Astley Cooper, and by others 
has been actually denied. I have seen no specimen obtained from the 
cadaver, except the doubtful one contained in Dr. Watts's cabinet, and 
of which I have furnished an account, accompanied with a drawing, in 
my report to the American Medical Association, 1 and the specimen 
owned by the late Dr. Mutter, of Philadelphia, of which he has kindly 
furnished me the following description : " History unknown. The 
line of fracture seems to have passed through the neck of the left 
radius, just at the upper extremity of the bicipital protuberance. 
Union with deformity has resulted. Owing to the fracture having 
taken place within the insertion of the biceps, that muscle appears to 
have drawn forward and upward the lower end of the short upper 
fragment. In consequence of this movement, the articulating facet of 

1 -Transactions, vol. ix, pp. 157 and 229. 



280 



FRACTURES OF THE RADIUS. 



Fig. 90. 



the head of the radius is tilted backwards, so as no longer to be in con- 
tact with the humerus. As a secondary consequence, the anterior edge 
of the head of the radius rests permanently against the articulating 

surface of the humerus. At this new point 
of contact a new surface of articulation is 
seen to have been formed, while the original 
articulating facet is directed backwards, 
and lies at right angles to the one of more 
recent formation. At the inner edge of the 
new articulation of the head of the radius 
with the humerus, contact with the ulna has 
developed another surface of articulation. 
The upper and lower fragments are united 
at an angle, and the radius does not appear 
to have lost in length." 

Velpeau has once demonstrated the exist- 
ence of this fracture in a dissection, but the 
fracture was accompanied with a fracture 
also of the coronoicl process ; and Berard 
obtained possession of a similar specimen. 
I do not remember to have seen a notice of 
any others. Malgaigne affirms, with his 
usual frankness, that although he has oc- 
casionally believed that he had met with 
it, the autopsy, whenever it has been ob- 
tained, has shown that it was rather a sub- 
luxation than a fracture. On the other 
hand, Mr. South calls it a "not unfrequent 
accident/ 7 but in confirmation of this dec- 
laration he cites no examples. 

While, therefore, the presence of what 
appear to be the rational diagnostic signs 
has compelled me to record one case as an uncomplicated fracture of 
the neck of the radius, and two others as fractures at this point accom- 
panied either with a fracture of the humerus or a dislocation of the 
ulna, I am prepared to admit that some doubt remains in my own 
mind as to whether in either case the fact was clearly ascertained ; nor 
do I think, speaking only of the simple fracture, that it will ever be 
safe to declare positively that we have before us this accident, lest, as 
has happened many times before, in the final appeal to that court 
whose judgment waits until after death, our decisions should be re- 
versed. 

Nothing, perhaps, could more fully illustrate the difficulty of diag- 
nosis in the case of injuries received in the neighborhood of the head 
of the radius than the testimony given in the case of Noyes vs. Allen, 
tried in the Supreme Court at Cambridge, January, 1856, before Judge 
Bigelow. Mr. Noyes injured his elbow, January 7, 1854, and Dr. 
Allen, who was called immediately, believed that the ligaments of the 
joint had been torn, but that no bones were broken or displaced. On 




Fracture of neck of radius (Mut- 
ter's cabinet), a. Original articu- 
lating facet, b, b. New articulating 
facets, c. Projecting fragments. 



FRACTURES OF THE NECK OF THE RADIUS. 281 

the following morning he was dismissed, and Mr. No^es went home. 
Three weeks later it was seen by Dr. Dow, who also thought there 
was no fracture. About eight weeks after the accident a physician ex- 
amined the arm, and declared the neck of the radius broken, and the 
fragments displaced; and when the case was finally brought to trial he 
testified still that such w r as certainly the fact; and five other physicians, 
not one of whom, however, we are told, was a member of the State 
Medical Society, testified positively that the radius w T as broken at its 
neck, producing a bony protuberance; that such an injury only could 
account for the symptoms manifested at the time of the accident, and 
that no other fractures or injuries of the joint could explain so well the 
present appearances of the arm. While, on the part of the defence, 
six of the most intelligent medical gentlemen of the State, Drs. Kimbal 
and Huntington, of Lowell, and Drs. Townsend, Lewis, Clark, and 
Gay, of Boston, testified that the head and neck of the radius were 
not displaced, nor was there any evidence that this bone had ever been 
broken. There is every reason to believe that these latter gentlemen 
were correct; yet it is to be presumed that the gentlemen who first tes- 
tified were not without some grounds for their opinions so confidently 
expressed. 

The case w T as given to the jury after a trial of five days, who promptly 
returned a verdict for the defendant. 1 

When this fracture occurs, the upper end of the lower fragment will 
probably be carried forwards by the action of that portion of the biceps 
which has its insertion into the tubercle; and the displacement in this 
direction must necessarily be increased in proportion as the arm is 
straightened. In the cabinet specimens belonging to Dr. Mutter, the 
line of fracture, commencing in the neck, has terminated in the tuber- 
cle; consequently the biceps, having still some attachment to the upper 
fragment as w^ell as the lower, has drawn them both forwards. 

The same anterior displacement I have noticed in all of the supposed 
living examples, but w 7 hether both fragments or only one had suffered 
displacement I am unable to say. 

A girl, set. 11, living in Ontario Co., N. Y., fell from a tree, and 
injured her right arm. Her surgeon, who regarded it as a fracture of 
the neck of the radius, reduced the fragments, and placed the forearm 
at a right angle with the arm. On the twenty-eighth day all dressings 
were removed, and the patient was dismissed; the fragments seemed to 
be in place. The parents, finding the elbow stiff, now made violent 
and successful efforts to straighten the arm. 

Fifteen months after the accident, the child was brought to me. 
There was at this time a bony projection in front, opposite the neck of 
the radius, which I believed to be the point of fracture. The hand 
was forcibly pronated, and she had only a limited amount of motion at 
the elbow-joint. The anchylosis was probably due to inflammation 
directly resulting from the severe contusion; but it is quite probable 

1 Amer. Med. Gazette, vol. vii, p. 299. 
19 



282 



FRACTURES OF THE RADIUS. 



Fig. 91. 



7 



that the forward displacement of the fragments was alone due to the 
too early and too violent attempts to straighten the arm; at least, this 
was the explanation which I ventured to give to 
the parents at the time. 

The second case occurred in a lad eight years 
old, living in Wyoming Co., N. Y. His parents 
brought him to me ten weeks after the injury 
was received, and I then found the forearm bent 
to a right angle with the arm, and anchylosed 
at the elbow-joint. The hand was also forcibly 
pronated, and could not be supinated. In front, 
and opposite the neck of the radius, there was 

/| i a distinct bony projection, which I believed to 

1 Mr ^ e ^ e P omt ' °f unwn of the bony fragments. 

; The external condyle seemed also to have been 

broken. 

The third example, treated originally by Dr. 
Nott, of Buffalo, was seen by me six months 
after the accident. The upper end of the lower 
fragment seemed to be displaced forwards. 
There was very little motion at the elbow-joint, 
and both pronation and supination were com- 
pletely lost. 

I have seen, in Dr. Mutter's cabinet, two 
specimens of fracture of the outer half of the 
head of the radius. In one case, the small frag- 
ment is slightly displaced downwards in the di- 
rection of the axis of the bone; and, in the other, 
the fragment is thrown outwards, or to the radial 
side. Both are firmly united in their new posi- 
tions. 

Dr. Hodges presented to the "Boston Society 
for Medical Improvement" a specimen very 
much resembling those of Dr. Mutter's, in which 
case the patient survived his injuries only six 
hours; and in the examination after death he 
was found to have also an oblique fracture of 
the shaft of the ulna, the line of fracture com- 
mencing above the coronoid process, and extend- 
ing obliquely downwards and backwards. He remarks, moreover, 
that he has three times found a longitudinal fracture of the head of the 
radius associated with a fracture of the coronoid process of the ulna. 1 
I have already observed that Velpeau had once noticed the same coin- 
cidence. 

In the treatment of fractures of the neck of the radius, we must not 
neglect to flex the forearm upon the arm, so as to relax, as completely 
as possible, the biceps, whose advantageous insertion into the tubercle 
of the radius would be certain to produce displacement, unless this 



; ^-y///0^£ 



Fracture of head of radius. 
(Mutter's Collection. Speci- 
men A, No. 105.) 



Hodges, Boston Med. and Surg. Journ., Dec. 6, 1866. 



t 
• FEACTUEES OF THE HEAD OF THE RADIUS. 283 

position was adopted. A single dorsal splint, properly padded, should 
support the forearm, while the surgeon, having placed a compress over 
the upper end of the lower fragment, proceeds to secure the whole with 
a roller. 

Especial care must also be taken to prevent the forearm from being 
extended before the bony union is fairly consummated, lest the biceps, 
now firmly contracted, should draw the lower fragment forwards, as 
it must inevitably do while the bony union is imperfect ; an accident 
which, there is some reason to believe, occurred in one of the examples 
which I have already cited. 

If the patient be a child, or if there is any reason to suppose that 
these rules will not be faithfully complied with, it would be well to 
secure the arm in this position with a right-angled splint. 

When the fracture occurs in any portion of the radius below the 
insertion of the biceps, and above the insertion of the pronator radii 
teres, Mr. Lonsdale suggests the propriety of placing the forearm in a 
condition of supination, at least so far as is practicable, for the purpose 
of securing a proper apposition of the fragments. His argument in 
favor of this practice is ingenious, and deserves consideration. 

When the bone is broken anywhere in this portion, the action of 
the pronators upon the upper fragment ceases ; while that of the biceps, 
which is a powerful supinator, continues; consequently the upper frag- 
ment becomes at once, and completely, rotated outwards or supinated. 
Now, if the hand, to which the lower end of the radius alone remains 
attached, should be forcibly pronated, the radius will also be rotated 
inwards upon its own axis ; and although it might be possible in this 
condition to bring the broken ends into contact, and a bony union, 
without deformity, might be consummated, yet the power of supination 
must be forever lost; since the union has been effected while the head 
and upper fragment are already in a state of complete supination ; and 
if such is the fact, it is evident that the whole bone, together with the 
hand, will be incapable of any further supination. 

It is not, indeed, the practice with any surgeons, so far as I know, 
to treat this fracture with the hand placed in a position of extreme 
pronation ; but the case has been supposed for the purpose of render- 
ing the argument more intelligible. The usual practice is to place 
the forearm and hand in a position midway between supination and 
pronation, and then to lay it across the body at a right angle with the 
arm ; but it is plain that the same objection, differing Only in degree, 
will apply to this position as to that of pronation. The axes of the 
two fragments are not made to correspond, since, while the lower frag- 
ment is only half rotated outwards, the upper fragment is completely, 
and the result of the union must be the loss of one-half the power of 
supination in the hand. 

It is only, then, by complete supination of the hand during treat- 
ment that this difficulty can be avoided, and I have no doubt that we 
ought to adopt this plan, whenever it is practicable to do so, or when- 
ever we are not hindered by serious obstacles ; and the only obstacle 
which occurs to me as likely to interpose itself, is the practical one 
which most surgeons must have experienced in treating all injuries of 



284 



FRACTURES OF THE RADIUS. 



the forearm, whether fractures, or only severe contusions of the mus- 
cles, etc., namely, the constant and almost uncontrollable tendency 
of the hand to assume the prone or semi-prone position. This is due, 
no doubt, to the great preponderance of power in the pronators ; and 
such is the resistance which they afford to supination that it is often 
quite impossible to lay the hand upon its back while the forearm is 
across the body, and, if accomplished, the position generally becomes 
in a few hours so painful as to be intolerable. By extending the arm, 
however, and laying it upon a pillow, the hand will be found again to 
rest easily upon its back, because in this way we avail ourselves of the 
outward rotation of the humerus at the shoulder-joint. 

Dr. X. C. Scott, formerly Resident Surgeon to the Brooklyn City 
Hospital, in his inaugural thesis, submitted in March, 1869, has dis- 
cussed very fully the advantages of this position in many fractures of 
the forearm, and he has devised a very ingenious mode of securing the 
limb after supination is effected, adding also a moderate amount of ex- 
tension by adhesive plasters and elastic bands. 

Fig. 92. 




Scott's apparatus for fractures of the forearm. 



Dr. Scott informs me that he has treated twenty-five cases very 
successfully at the Brooklyn City Hospital and elsewhere, by this 
method. 

It has already been stated that of the whole number of fractures of 
this bone recorded by me, amounting in all to one hundred and nine, 
only eight belonged to the middle third ; an observation which is in 
striking contrast with the remark of Chelius, that it is broken most 
frequently in its middle. 

If the fragments are completely separated in the middle third, the 
lower end of the upper half is drawn forwards by the action of the biceps 
aided by the pronator radii teres, in case the fracture is below its inser- 
tion; while the lower fragment is tilted toward the ulna by the con- 
joined action of the supinator radii longus and pronator quadratus. 
But as to the direction of the displacement much will depend upon the 
direction of the force bv which the fracture has been occasioned. 



FRACTURES OF THE HEAD OF THE RADIUS. 285 

A laboring man, set. 35, broke the radius near the lower end of the 
middle third. On the same day I replaced the fragments as well as I 
could in the midst of the swelling which had already occurred, and 



Fig. 93 




Fracture of the shaft of the radius. (From Gray.) 

applied two broad and well-padded splints, one to the palmar and one 
to the dorsal surface of the forearm. 

On the twenty-eighth day I first discovered that the fragments were 
projecting in front, and I at once proposed to thrust them back by 
force, but the patient declined allowing me to do so. I then applied a 
compress near the summit of the projection, but not exactly upon it, 
lest it should cause ulceration, and secured over this a firm splint. At 
first this seemed to produce a change in the fragments, but after a 
couple of weeks I found there was no improvement, and it was discon- 
tinued. About six months after the fracture occurred, this man had 
the same arm terribly lacerated in a railroad accident, and I was 
obliged to amputate near the shoulder-joint; and I thus obtained the 
broken radius. The bone was firmly united, but with an angle, salient 
forwards, of about ten degrees. There was no inclination toward the 
ulna. 

My impression is that these fragments were never completely re- 
placed, a point which I could not well determine at first on account of 
the rapid effusion. If they had been, I think they could have been 
retained in place with the appliances used. Almost every day the limb 
was examined, and as often as every fourth or fifth day the dressings 
were removed and carefully reapplied. And only once did they be- 
come so loose as not to afford the requisite support, and this at a period 
too late to have occasioned the deformity. 

We ought not to be deceived, therefore, and promise too confidently 
a perfect limb, even when but the radius is broken, since we may not 
always be certain that the ends are well replaced, or perhaps they may 
become displaced subsequently, and in either case we are not likely to 
discover the deformity until the swelling has subsided, and it is too late 
to apply the remedy. 

In the treatment of fractures of the middle third, the same rules, 
with only slight modifications, will be applicable, as in fractures of 
both bones. Two straight, long, and broad splints must be applied 
after being carefully padded ; and especial attention should be paid to 
the tendency of the fragments to become displaced forwards and toward 



286 FRACTURES OF THE RADIUS. 

the ulna tli rough the action of both the biceps and the pronator radii 
teres; a tendency which may in some measure be provided against by 
flexion of the arm, but which must be overcome chiefly by steady and 
well-adjusted pressure, near, but not upon, the ends of the fragments. 

Fractures of the lower third, occurring above the line of Colles's 
fracture, are almost as rare as fractures of the middle or upper thirds. 
I have recorded five ; one of which it will be proper to relate as a rep- 
resentative example. 

George Vogel, set. 30, was admitted to the Buffalo Hospital of the 
Sisters of Charity, Nov. 2, 1852, with a fracture of the right radius 
about three and a half inches above its lower end. The hand was 
prone, and inclined to the radial side; while the broken ends of the 
radius fell against the ulna, from which it was found difficult to sepa- 
rate them. The lower end of the ulna was prominent, and projecting 
upon the ulnar margin of the hand. 

I was unable completely to separate the fragments of the radius from 
the ulna, by either pressure with my fingers between the bones, or by 
seizing upon them with my thumb and fingers. Having, however, 
adjusted them as well as possible, I flexed the arm, and applied a broad 
and well-padded splint to the palmar surface of the forearm, securing 
it in place with a paste bandage. These dressings were finally removed 
at the end of four weeks, when I found scarcely any displacement or 
deformity remaining. 

Most of these fractures, when properly treated, result in perfect limbs. 
In a certain proportion, however, it will be found impossible effectually 
to resist the action of the pronator radii teres and of the quadratus, and 
the fragments will unite at an angle resting against the ulna, and some- 
times, by the interposition of intermediate callus, they will become 
firmly united to the ulna. Occasionally, also, especially where the 
fracture has been produced by a fall upon the hand, and the radio-ulnar 
ligaments of the wrist have been torn or stretched, the lower end of the 
ulna will be found to project permanently, and the hand to fall more or 
less to the radial side. 

Of the ninety-eight fractures belonging to the lower third of the 
radius, ninety-three were near the lower end, or within from half an 
inch to one inch and a half from the articular surface, all being in- 
cluded in those fractures called "Colles's fractures/' most of which were 
no doubt true fractures, and probably a small proportion separations of 
the epiphyses. 

In every instance, except one, which has come under my notice, 
where the cause of a Colles's fracture has been ascertained, it has been 
occasioned by a fall upon the palm of the hand. The exceptional case 
was in the person of Mrs. D. B., who fell in getting out of a street car 
in the city of New York, May 20th, 1865, striking upon the back of 
her hand while the hand was shut. The displacement was in the same 
direction as in cases caused by a fall upon the palm. Robert Smith 
has seen a similar accident cause a displacement of the fragment for- 
wards. 

Colles described this fracture as occurring always about one inch 
and a half above the carpal end of the bone ; but Robert Smith, who 



287 

has carefully examined all of the cabinet specimens he could find, 
about twenty-three in number, has never seen the line of fracture 
removed farther than one inch from the lower end of the bone, and 
in several specimens it was within one-quarter of an inch of this 
extremity. Dupuytren has also described the fracture as occurring 
from three to twelve lines above the joint. I think I have found the 
fracture generally as low as these latter surgeons have placed it, but 
occasionally as high as it was placed by Colles. 

Fig. 94. 




Fracture of the radius near its lower end. 

Case. A woman, set. 40, fell upon the sidewalk, striking upon the 
palm of her left hand. She was brought immediately to my office, 
and I found the radius was broken about one inch and a half above 
the wrist. The lower fragment was tilted back considerably. Hand 
prone. 

Placing my thumb against the back of the lower fragment, it was 
easily restored to position, and with only a slight crepitus. When 
my thumb was removed it manifested no tendency to displacement. 
The arm was dressed with a curved palmar splint, secured in place 
with a roller applied moderately tight. On the seventh day a straight 
splint was substituted for the curved. The arm was examined almost 
every day, and the dressings occasionally renewed until the twenty- 
sixth day, when the splint was finally removed. The wrist was at 
this time only slightly anchylosed, and there seemed to be no deformity 
or imperfection remaining. Passive motion, which had been practiced 
at each removal of the dressings, was directed to be continued. 

Case. A boy, set. 11, was brought to me, having just fallen from a 
pair of stilts. His right radius was broken transversely, three-quarters 
of an inch above the wrist, and the lower fragment was much tilted 
back ; the lower end of the ulna was prominent, and the hand fell to 
the radial side. 

Pushing from behind, the lower fragment was made to resume its 
place, and the deformity immediately disappeared. It was noticed, 
however, that it required unusual force to accomplish this, but it was 
not found necessary to use extension. There was also, accompanying 
the reduction, a slight crepitus. 

The treatment was the same as in the first case, except that the 
curved splint was employed throughout. Little or no deformity ex- 
isted when the dressings were removed. 

Case. George Lofinch, set. 42, fell upon an icy sidewalk, striking 
upon the palm of his left hand. Fracture three-quarters of an inch 



288 FRACTURES OF THE RADIUS. 

above the lower end. Fragment displaced backwards. A friend had 
partially replaced the fragment by pushing upon it, before he came to 
me. Within half an hour after the accident he was at my office, and 
I restored the lower end of the bone very easily to place by pushing 
from behind with my thumb. No extension was necessary. It would 
not, however, remain in place unless the forearm was pronated so that 
the weight of the hand could aid in the retention. 

I applied my own palmar splint. The recovery was rapid and 
complete. 

Case. Margaret Reed, set. 48, fell, September 23, 1855, striking on 
the palm of the left hand, and breaking the radius about one inch from 
its lower end. One week after, she came under my care at the hos- 
pital. The arm had been previously dressed carefully by one of my 
colleagues, with curved dorsal and palmar splints ; but, on examina- 
tion, we found the fragments a good deal displaced. It was found 
necessary now to use both extension and pressure from behind to re- 
store the lower fragment to position. This we finally succeeded in 
doing, and immediately splints were again snugly applied. Two days 
after, on opening the dressings, the lower fragment was a second time 
found displaced backwards. It was again reduced, but only by using 
great force. Fifteen days 'later, we were pleased to find the bone firm 
and without deformity. 

Margaret left the hospital on the 4th of November, with her hand 
and wrist still swollen, and with a good deal of stiffness at the elbow 
and wrist-joints. 

Case. Charles Stratton, a healthy and temperate laborer, set. 36, 
fell forwards from a wagon, November 22, 1854, striking upon the 
palm of his hand, and breaking the radius a little more than one inch 
above the joint. I found the lower fragment displaced backwards, and 
it was easily reduced by pressure in the opposite direction. The fore- 
part of the wrist being quite tender to pressure, the splint was applied 
to the dorsal surface of the forearm. The splint was curved (pistol- 
shaped), and the surface which was applied to the arm was padded 
with care; it was secured in place by a few light turns of a roller, and 
laid across the body in a sling. 

The arm was seen by me on each of the succeeding seven days, and 
on the third, fifth, and seventh days the splint was removed completely ; 
but on this last day an erysipelatous inflammation had commenced in 
the neighborhood of the wrist. The splint and roller were therefore 
not reapplied, but the limb was laid upon a broad board, cushioned 
and covered with oiled silk, and cool water irrigations were directed. 
The inflammation soon subsided, but the splint was never resumed, as 
the fragments were found to stay in place perfectly without its aid. 
At the end of five weeks, union seemed to be consummated ; and one 
year later the bone was found to be perfectly straight, yet the wrist- 
joint and the finger-joints remained stiff, so much so that he was un- 
able to perform any labor. The stiffness was, however, gradually 
disappearing, while all swelling and tenderness had long ceased. 

The observations of M. Voillemier also have shown that, instead of 
being oblique, as has generally been supposed, the fracture is almost 



FRACTURE. 289 

uniformly transverse from the palmar to the dorsal surfaces of the bone, 
and only occasionally slightly oblique in its other diameter, or from the 
radial to the ulnar side. I have seen, however, in the museum of the 
College of Physicians of Philadelphia, a specimen of this fracture in 
which the line of fracture is transverse, from side to side, but very 
oblique from before backwards, and from below upwards. There is 
also a line of incomplete fracture extending into the joint. It is united 
by bone, with the usual displacement backwards. 

The observations of both R. Smith and Voillemier have shown, 
moreover, that the displacement of the lower fragment is seldom suffi- 
cient to enable it to escape completely from the upper; and that where, 
in extremely rare instances, and in consequence of extraordinary vio- 
lence, such complete separation does occur, a disruption of those liga- 
ments which attach the lower fragment to the ulna occurs also, and the 
deformity becomes at once very great, so that it no longer presents the 
peculiar features of Colles's fracture, but resembles a dislocation. 

In the so-called Colles's fracture, the lower and outer border of the 
radius, or its styloid apophysis, is swung around or tilted, as it were, 
upon the ulna; the lower and inner border of the same fragment being 
retained in place by the radio-ulnar ligaments, which do not usually 
suffer a complete disruption, but only a stretching or partial laceration. 
The upper or broken margin of the lower fragment, and also the ulnar 
margin, undergo very little displacement; while the lower or articular 
surface, and the radial margin, are carried backwards, upwards, and 
outwards. 

Surgeons have spoken of a falling in of the upper end of the lower 
fragment toward the ulna, as an almost inevitable result of the action 
of the pronator quadratus, and against which tendency they have sought 
carefully to provide; but there is much reason to believe that any con- 
siderable degree of displacement in this direction is a rare event, and 
that, when it does- exist, it is in consequence mostly of the direction of 
the force which has produced the fracture rather than of the action of 
this muscle, only a few of the fibres of which are usually attached to 
the lower fragment, and, in some instances, when the fracture is within 
a half or quarter of an inch of the articulation, not any. Besides, there 
is actually in these latter cases no interosseous space into which the 
fragment may fall, and its displacement toward the ulna becomes, 
therefore, impossible. 

Still, however, if one were disposed to speculate upon the condition 
of these parts after the fracture, it might perhaps be easy to persuade 
ourselves that the action of the pronator quadratus upon the upper 
fragment, whose broken extremity was not completely, or at all, dis- 
engaged from the lower, would carry both fragments together toward 
the ulna. But whatever might be the result of our speculations, still 
the fact, as proved by specimens, is not generally so; and this is not 
the first time that facts and theories have disagreed. 

The truth is, that it is unusual to find any of the museum specimens 
of this fracture thus united. But they may be found constantly tilted 
back in the manner I have described, occasionally tilted forwards, and, 



290 FRACTURES OF THE RADIUS. 

still more rarely, slightly displaced upon their broken surfaces antero- 
posteriorly. 

The general absence of this internal displacement may find its ex- 
planation in the direction of the force which generally produces this 
fracture, in the occurrence of the fracture sometimes at a point so low 
as to render its displacement in this direction impossible, and in the 
breadth of the bone, at the seat of the fracture, which does not permit 
it to fall laterally without actually increasing its length; a circumstance 
which its secure ligamentous attachment to the ulna at its opposite ex- 
tremities, and its complete apposition to the wrist and elbow-joint, do 
not allow. 

The mistake of those surgeons who have attempted to describe this 
fracture has originated in the appearance presented in nearly all recent 
fractures occurring at this point. The hand falls to the radial side, and 
seems to carry the lower end of the lower fragment with it, while the 
lower end of the ulna becomes unnaturally prominent in front and to 
the ulnar side; a condition of things which has naturally enough been 
ascribed to the displacement of the upper end of the lower fragment in 
the direction of the interosseous space. 

But this same radial inclination of the hand, and prominence of the 
ulna, are present frequently when the radius is broken at its lower end, 
and no displacement in any direction has taken place; and I have even 
observed it in simple sprains of the wrist, and in the hands of old or 
feeble persons where all the ligaments have become relaxed. 

It is seen, however, in a more marked degree when the bone is actu- 
ally both broken and displaced backwards in its usual direction. In 
short, the deformity in question is due, in a large majority of instances, 
to the relaxation, stretching, or more or less disruption of the radio- 
ulnar ligaments, which permits the hand to fall to the radial side by a 
simple rotatory movement over its articular surface. For this reason, 
also, because these ligaments once lengthened or broken can never, or 
only after a lapse of many years, be completely restored, this deformity 
may be expected, in a certain number of cases, to continue, however 
exact and perfect may be the bony union. 

It must be added, however, that so long as the tilting of the fragment 
remains, the articular surface is actually presenting somewhat to the 
radial side. While in the normal condition it presents downwards, for- 
wards, and inwards, it now presents, when the displacement is consid- 
erable, downwards, backwards, and outwards. 

Diday maintained that there existed usually in this fracture an over- 
lapping or shortening of the bone in its entire diameter, and Voillemier 
thought that the specimens which he had examined proved that an 
impaction was almost universal. 

Both of these opinions have been combated by Robert Smith; the 
shortening observed by Diday being found only on that side of the bone 
to which the hand inclines, and being, according to Robert Smith, the 
result of the motion of the lower fragment already described ; and the 
appearance of impaction being due to the ensheathing callus, which is 
deposited usually, if the displacement is allowed to continue, in the re- 
tiring angle opposite the seat of fracture. 



COLLES S FRACTURE. 



291 



These are questions, however, requiring for their decision a very 
careful study of specimens, and in relation to which farther observa- 
tions may be necessary. Indeed, some recent observations made by 
Mi. Callender, of Saint Bartholomew's Hospital, London, go far to 
sustain the opinion of Diday, that some impaction generally exists, 
bnt rather upon the posterior margin than upon either the radial or 
ulnar side. 1 

In the accompanying woodcut (Fig. 95) is seen an impacted and 
comminuted fracture of the lower end of the radius. Dr. James TTent- 
worth, of Troy, N. Y., who sent me the specimen, says that the patient, 
a man, set. 50, in a fit of delirium jumped from a third-story window, 
alighting upon the stone pavement. He survived the accident less 
than one hour. 

The next illustration (Fig. 96) is from a specimen presented to me by 
Dr. William Van Buren, and was found in an autopsy at the New York 
City Hospital. In this specimen there is comminution, without im- 



FiG. 95. 



Fig. 



Fig. 97. 






Impacted fracture. (Au- 
thor's collection.) 



Comminuted fracture. (Author's 
collection.) 



Bigelow's case of commi- 
nuted fracture of the lower 
end of the radius. 



paction or displacement. The line of separation between the upper 
and lower fragments is transverse, and the lower fragment is divided 
into five distinct pieces, each line of fracture involving the joint. 

One curious example of this form of fracture is reported by Dr. 
Bigelow, of Boston (Fig. 97). The patient had fallen, and being other- 
wise seriously injured, ultimately died in the Massachusetts Hospital. 
At first he had only complained of lameness at the wrist, as if it had 
been severely sprained ; but at the end of several days the joint be- 
came swollen, and from the persistence of the swelling Dr. Bigelow 
was led to diagnosticate a stellate crack in the articulating extremity 
of the radius, he having met with a similar case two years before, when 



1 Callender, St. Barth. Hosp. Kep., p. 281, 1865. 



292 FRACTURES OF THE RADIUS. 

a patient with the same symptoms had died of other injuries, and ex- 
hibited a crack in the same place, but less extensive than in this case. 
There was found, in this last example, a star-shaped fissure on the 
articulating surface, without displacement. These fissures penetrated 
the shaft for an inch or more. Dr. Bigelow thought that the bones of 
the wrist acted as a wedge to spread the corresponding hollow of the 
articulating extremity, and that this specimen would explain the per- 
sistence of some cases of sprained wrist. 1 

There is no doubt that occasional examples may be found illustrat- 
ing one or more of all these varieties of displacement, and that to the 
impaction is sometimes added a comminution of the lower fragment, 
the lines of the fracture extending freely into the joint. 

Robert Smith has described a fracture occurring at the same point, 
and probably possessing nearly the same characters as Colles's fracture, 
in which the lower fragment is thrown forwards instead of backwards, 
and which has generally been the result of a fall upon the back of the 
hand. There is no such specimen, however, in any of the pathological 
collections in Dublin, nor has Mr. Smith ever seen a specimen obtained 
from the cadaver, although he reports a case which fell under his ob- 
servation in practice. 

I have myself seen one such case, 2 but I regret to say that my ex- 
amination of the condition of the arm was not such as to enable me to 
add anything to the information already possessed upon this subject; 
indeed, until we have an opportunity of studying it in the cadaver, we 
cannot speak very definitely of its anatomical characters. 

Nelaton observes that all the varieties of this fracture which he has 
seen are often accompanied with fracture of the styloid apophysis of 
the ulna, and with a tearing of the triangular ligament. I am not 
aware that any other writer has made the same observation in relation 
to the frequent occurrence of a fracture of the styloid apophysis of the 
ulna, and I think the accident is not so common as the remark of 
Nelaton would lead us to suppose. 

Dr. Butler, House Surgeon to the Brooklyn Hospital, reports a case 
of fracture of the right radius at the junction of the middle and lower 
thirds, accompanied with a fracture also of the styloid apophysis in 
the same bone. The accident occurred in a lad fourteen years old, 
who had fallen from a height of thirty feet upon the pavement. The 
lower fracture commenced at the base of the styloid process of the 
radius, and extended down obliquely into the wrist-joint, breaking off 
about one-fifth of the articular surface. The process was drawn up on 
the posterior surface of the radius, about one inch and a half, by the 
supinator radii longus muscle. It was movable, but, in consequence 
of the contusion and swelling, could not be returned to its place. The 
hand occupied the same position that it does in Colles's fracture. 

On the eighth day an attempt was made to force down the process 
with a compress secured by adhesive plaster straps ; but it could not 
be done. The hand and arm were confined also to a pistol-shaped 

1 Boston Med. and Surg. Journ., vol. lviii, p. 99. 

2 Trans. Am. Med. Assoc, vol. ix, p. 145. 



FRACTURE. 293 

splint; ulcerations ensued from the pressure of the compress, and the 
process was laid bare, but it finally became united in its abnormal 
position ; the motions of the wrist, however, were not impaired, and 
the power of pronation and supination soon returned. 1 

I believe I have seen two examples of a fracture commencing on 
the radial side of the bone and terminating in the joint, the separated 
fragment including considerable more than the apophysis ; but neither 
of these cases has been verified by an autopsy. They were described 
in detail in the third edition of this book. 

Recently Dr. E. Moore, of Rochester, X. Y., has demonstrated by 
examinations upon the cadaver and by experiment, that in a certain 
proportion of cases the internal lateral ligament, and the triangular 
fibro-cartilage having given way under the force which has occasioned 
the fracture, the styloid process is thrust under the annular ligament 
and imprisoned ; in fact, the ulna becomes dislocated, and is retained 
by the annular ligament in its new position. Nor can the reduction 
of the fracture be accomplished until the ulna is released from its im- 
prisonment. Reduction is to be accomplished by extension and partial 
circumduction; the hand being grasped firmly and extended first to 
the radial side, then backwards to the ulnar side, and finally forwards, 
or in the position of flexion. During the entire manoeuvre the wrist is 
held firmly by the opposite hand of the surgeon. The test of reduc- 
tion is to be found in the presence of the head of the ulna on the radial 
side of the ulnar extensor. 

In order to retain the ulna in place when reduction is effected, Dr. 
Moore places a thick, firm compress over its lower end, on the palmar 
and ulnar margins of the forearm, and secures this in place with a 
broad band of adhesive plaster drawn firmly around the wrist. The 
forearm is then placed in a narrow sling passing under the wrist and 
compress. This completes the dressing. 2 

In the first volume of the Philadelphia Medical Examiner (1838) 
will be found a description, by J. Rhea Barton, of Philadelphia, of a 
form of fracture occurring through the lower end of the radius, which 
is probably much less common than Colles's fracture, and which had 
hitherto escaped the notice of surgeons. Its peculiarity consists in 
the line of fracture extending very obliquely from the articulation, 
upwards and backwards, separating and displacing the whole or only 
a portion, as the case may be, of the posterior margin of the articu- 
lating surface. I have not recognized this fracture in any instance 
which has come under my own observation, nor have I been able to 
find a cabinet specimen in any pathological collection. Dr. Barton 
was not able to prove the correctness of his diagnosis by an autopsy, 
and the only well-authenticated example which I can find upon record 
is that to which Malgaigne has alluded, as having been seen by M. 
Lenoir, and of which an account was published in the Archives Gene- 
rales de Medecine, in 1839. M. Lenoir believed it to be a simple 
luxation of the hand backwards, but the patient having died, he was 

1 New York Journ. of Med., 1857. 

2 Moore, New York Med. Rec., April 1, 1870.. 



294 FRACTURES OF THE RADIUS. 

able to correct his diagnosis by an autopsy. A considerable fragment 
had been broken from the posterior lip of the articular surface, the 
line of fracture being from below upwards, and from before back- 
wards. This fragment had become displaced upwards and backwards, 
carrying with it the carpal bones, and producing thus the appearance 
of a simple dislocation. 1 I believe that the accident so carefully de- 
scribed by Barton was either a Colles's fracture, or a fracture simply 
of the radial margin, of which I have given two supposed examples, 
with the usual signs of which his account so exactly coincides, and that 
it was not a fracture of the posterior lip of the articulating surface, as 
he believed. 

Ninety-eight examples of fracture of the lower third of the radius 
have furnished no cases of non-union, nor indeed do I remember ever 
to have seen the union delayed ; yet only twenty-six are positively 
known to have left no perceptible deformity or stiffness about the 
joint: it is probable, however, that the number of perfect results might 
be somewhat extended, inasmuch as in very many of the cases the final 
results have not been noted. In one example, the case of a man whose 
arm was broken in Germany, when he was only ten years old, the 
fragments of the radius were driven into each other, or overlapped one 
inch, and the ulna had been displaced downwards toward the fingers 
the same distance. This was examined twelve years after the accident, 
and he had then a very useful arm. Twice I have found the wrist and 
finger-joints quite stiff after a lapse of one year ; in one case I have 
found the same condition after two years, in one case after three years, 
and in two cases after five years. 

If we confine our remarks to Colles's fracture, the deformity which 
has been observed most often consists in a projection of the lower end 
of the ulna inwards. In a large majority of cases this is accompanied 
with a perceptible falling of the hand to the radial side, while in a few 
it is not. After this, in point of frequency, I have met with the back- 
ward inclination of the lower fragment. Robert Smith found this 
displacement almost constant in the cabinet specimens examined by 
him; and it is very probable that nearly all of the examples examined 
by myself would present more or less of the same deviation upon the 
naked bone ; but in the living examples a slight deviation would be 
concealed by the numerous tendons which cover this part of the arm, 
and perhaps by some permanent effusions, of which I shall speak more 
particularly presently. 

There remains for a long time, in a majority of cases, a broad, firm, 
uniform swelling on the palmar surface of the forearm, commencing 
near the upper margin of the annular ligament and extending upwards 
two inches or more. This swelling continues much longer in old and 
feeble persons than in the young and vigorous. It is pretty generally 
proportioned to the amount of anchylosis existing at the wrist and 
finger-joints, and it disappears usually pari passu with these condi- 
tions. There can be no doubt that this phenomenon is due to effusions 
along the sheaths of the tendons, and in the areolar tissue external to 

x 700. 



FRACTURE. 295 

the sheaths, and it is as often present after sprains and other severe 
injuries about this part, as in fractures. In many cases, however, its 
prolonged continuance and its firmness have led to a suspicion that 
the bones were displaced, a suspicion which only a moderate degree of 
care in the examination ought easily to dispel. A similar effusion, but 
in less amount, is frequently seen also on the back of the hand, below 
the annular ligament. When both exist simultaneously the appear- 
ances of deformity and of displacement are greatly increased. Here, 
then, we shall find a partial explanation of the anchylosis in the wrist 
and finger-joints, which continues occasionally many months, or even 
years, if, indeed, it is not permanent; an anchylosis produced in a 
few instances by extension of the inflammation to these joints, but 
much more often by the inflammatory effusion and consequent ad- 
hesions along the thecse and serous sheaths, through which the tendons 
all pass in their course to the hands and fingers, and also by simple 
contraction of the articular ligaments, as a consequence of disuse, or, 
as it is usually termed, by passive contraction of these ligaments. The 
fingers are quite as often thus anchylosed after this fracture as the 
wrist-joint itself; a circumstance which is wholly inexplicable on the 
doctrine that the anchylosis is due to an inflammation in the joints. 
Indeed, I have seen the fingers rigid after many months, when, having 
observed the case throughout myself, I was certain that no inflamma- 
tory action had ever reached them. 

The peculiar swellings of the wrist and hand which have been de- 
scribed above, commence to show themselves very early after the 
receipt of the injury; but I have noticed, also, a swelling which is a 
little later in its accession, namely, an induration and fulness upon the 
back of the hand, which corresponds accurately to the position of the 
carpal bones, and presents an appearance as if all the carpal bones were 
slightly displaced backwards. This phenomenon is probably due to 
a swelling and induration of the numerous ligaments which bind 
together their bones posteriorly. It usually disappears after a few 
months. 

Nor is it any more difficult to show, I think, that the anchylosis of 
the wrist-joint is not often due to a malposition of its articular surfaces, 
as has frequently been asserted in the written treatises. 

The most superficial examination of the mechanism of this joint 
ought to satisfy us, that any moderate or even considerable malposition 
of the lower fragment after a fracture of the radius, is not sufficient in 
itself to occasion anchylosis. It is true that in the fracture now under 
consideration, the direction of the articular surface of the radius is 
changed, and that, while it was directed downwards, forwards, and to 
the ulnar side, it is now, perhaps, directed downwards, backwards, and 
to the radial side. But of what consequence is this so long as the carpal 
bones, with which alone this bone is articulated, preserve their relations 
to the radius unchanged? 

If any other evidence be demanded, it may be supplied by the ex- 
perience of most surgeons in examples of anchylosis without displace- 
ment ; in examples of displacement without anchylosis, but in which 
the anchylosis has yielded gradually to the lapse of time, while the dis- 
placement has continued. The following case is in point : James Ryan, 



296 FRACTURES OF THE RADIUS. 

a private in the 15th N. Y. volunteers, fell from a height into a ditch 
during the battle of Fair Oaks, Va., May 31, 1862, striking upon the 
palm of his left hand, and causing a simple fracture near the lower end 
of the radius, accompanied probably with impaction. I do not know 
what treatment was adopted, but when he came under my observation, 
in March, 1863, at the Central Park General Hospital, New York, I 
found the most extraordinary deflection of the hand to the radial side 
which I have ever seen after this fracture. The hand could be turned 
laterally, to a right angle with the arm; yet the motions of flexion and 
extension at the wrist-joint were nearly as perfect as in the opposite 
arm, and the hand was in all respects as useful as before the accident. 

To what I have said as to the prognosis in these accidents, I may be 
permitted to add the opinion of our distinguished countryman Dr. 
Mott, given in a clinical lecture before his class in the University of 
New York. 

" Fractures of the radius within two inches of the wrist, where treated 
by the most eminent surgeons, are of very difficult management so as 
to avoid all deformity; indeed, more or less deformity may occur under 
the treatment of the most eminent surgeons, and more or less imper- 
fection in the motion of the wrist or radius is very apt to follow for a 
longer or shorter time. Even when the fracture is well cured, an an- 
terior prominence at the wrist, or near it, will sometimes result from 
swelling of the soft parts." 

To which the reporter, himself a surgeon in the city of New York, 
adds : 

"As the above opinion of Professor Mott coincides with my own 
observations, both in Europe and in this city, as well as with many of 
our most distinguished surgical authorities, I venture to hope that it 
may assist in removing some of the groundless and ill-merited asper- 
sions which are occasionally thrown on the members of our profession 
by the ignorant or designing." 1 

In evidence that we have not yet attained all that we could desire 
in the treatment of this fracture, I will quote farther : 

" In young subjects, fractures of the lower end of the radius are easily 
reduced, unite readily, and leave the use of the limb perfectly unim- 
paired ; but in old persons, who, as before stated, are especially liable 
to this injury, the result is often most unsatisfactory, even after the 
greatest care has been used during the treatment. It is frequently 
months before the hand is free from pain and regains its proper motions, 
and too often an unsightly, crooked, and permanently stiff wrist re- 
mains, to the great inconvenience and annoyance of the patient." 2 

"Union occurs in about a month, but rarely without some displace- 
ment." 3 

"In a large number of cases it is impossible to loosen the impacted 
fragments." 4 Ashhurst and Gross express similar opinions. Let me 
add that several cases treated lately, under my observation, by the 

1 Boston Med. and Surg. Journal, vol. xxv, p. 289. 

2 Holmes's System of Surgery, American ed., 1870, vol. 2, p. 798. 

3 Gant's System of Surgery, London, 1871, p. 463. 

4 Bryant's' Surgery, London, 1872, p. 937. See also opinion of Callender on same 
page. 



S FRACTURE. 297 

plaster of Paris and by Moore method, both of which have recently 
been much employed in this country, have given no better average re- 
sults than have been obtained by other methods. 

Of gangrene as an occasional result of this fracture, I shall speak 
presently, in connection with the subject of treatment. 

The peculiar character of the displacement which characterizes 
Colles's fracture, and the constant difficulty experienced by surgeons 
in obviating deformity, have led to much speculation and ingenious 
invention ; and modern surgeons, especially, have thought it necessary 
to introduce here an essential modification of the usual apparel for 
broken forearms. This modification consists in employing a pistol- 
shaped splint, instead of a straight splint, by means of which the hand 
may be thrown more or less strongly to the ulnar side. 

Heister 1 speaks of inclining the hand toward the ulna, w T hile reduc- 
ing a fracture of the radius, but when the reduction has been effected 
he recommends a straight splint. 

Among the first to advocate the permanent confinement of the hand 
in this position, were Mr. Cline, 2 and M. Dupuytren. 3 Mr. Cline, and 
after him Bransby Cooper, 4 and Mr. South, 5 recommend the ordinary 
straight splints for the forearm, but the rollers by w T hich the splints are 
secured in place are not permitted to extend lower than the wrist; so 
that when the forearm is suspended in a sling, in a state of semi-pro- 
nation, the hand shall fall by its own weight to the ulnar side. 

Dupuytren, and after him, Chelius, adopt, in addition to the palmar 
and dorsal splints, the "attelle cubitale," or ulnar splint; which is a 
gutter, composed of steel, iron, tin, or some other metal, and made to 
fit the ulnar margin of the forearm and hand, when the hand is drawn 
forcibly to the ulnar side. Blandin, 6 Nelaton, 7 and Goyraud, 8 also, 
under certain contingencies employ the same. 

Most surgeons, however, employ either a palmar or a dorsal splint ; 
or both palmar and dorsal splints constructed with a knee, or pistol- 
shaped, and they thus avoid the necessity of the ulnar splint. Thus, 
Nelaton, 9 Robert Smith, 10 and Erichsen, 11 recommend this peculiar form 
only in the dorsal splint; while Bond, 12 Hays, 13 E. P. Smith, 14 G. F. 
Shrady, 15 and others, especially among the Americans, place the pistol- 
shaped splint against the palmar surface of the forearm and hand. 

A few modern surgeons have not seen fit to adopt this peculiar prin- 
ciple of treatment, or this form of dressing under any of its modifica- 

1 De Lavrentii Heisteri, Institutiones Chirurgicse, pars prima, p. 203, Amsterdam 
ed., 1739. 

2 Malgaigne, Traite do Frac, etc., torn, i, p. 614, Paris ed. 

3 Dupuytren on Bones, London ed., p. 140. 

4 B. Cooper, Lectures on Surg., p. 232, American ed. 

5 Chelius's Surg., vol. i, p. 613. 6 Malgaigne, op. cit., torn, i, p. 614. 

7 Nelaton, Elem. de Path. Chir., torn, i, p. 747. 

8 Ibid., p. 746. 

9 Nelaton, op cit., p. 747. 10 R. Smith, op. cit., p. 168. 

11 Erichsen, Surgery, p. 215. 

12 Bond, Amer. Journ. Med. Sci , April, 1852. " ibid., Jan. 1853. 

14 E. P. Smith, Buffalo Med. Journ., vol. ix, p. 225. 

15 Shrady, Am. Med. Times, 2 cases, Dec. 22, 1860. 

20 



298 



FRACTURES OF THE RADIUS. 



tions. Colles 1 recommends a straight palmar and dorsal splint, and 
does not incline the hand. Barton 2 advises the same, and Skey, hav- 
ing declared his preference for a couple of broad, straight splints, adds: 
" Great care should be taken to prevent the hand falling, and this ob- 



FlG. 98. 




Nelaton's splint for fracture of the radius. 



ject will be attained by inclosing the entire forearm and hand in a well- 
applied sling." 3 

Stephen Smith employs two broad, straight, palmar and dorsal 




Bond's splint. 



splints, secured in position by adhesive strips, the hand being thrown 
to the ulnar side by reversed turns of adhesive plaster. 



Fig. 100. 




Hay's splint. 



Professor Fauger, of Copenhagen, has undertaken to treat this frac- 
ture in some sense without any splint, the forearm and hand being 



1 Colles, Lectures on Surgery, p. 325. 
3 Skey, Operative Surgery, p. 161. 



* Barton, Phil. Med. Exam., 1838. 



COLLES S FRACTURE. 



299 



simply laid over a double-inclined plane, so as to bring the wrist into 
a state of forced flexion. "The hand having been brought into a posi- 
tion of strong flexion, the forearm is placed, pronated, on an oblique 
plane, with the carpus highest, the hand being permitted to hang freely 
down the perpendicular end of the plane." l M. Yelpeau, in a report 



Fig. 101. 



cr~ 




E. P. Smith's splint. Surface applied to forearm. A. Forearm piece, made of felt, with 
incurvated margins. 

of his surgical clinic at La Charite" for the year ending September, 
1846, says this plan has been tried during the year, and "the result 



Fig. 102. 



c 




E. P. Smith's splint. B. Opposite surface. D, the hand-block, is connected with the forearm piece 
by two circular brass plates, which move upon each other, in order that the hand-block may assume 
any desired angle with the arm. In this way it may be adapted to either the right or left arm. It 
is fixed by a nut, seen on the brass plate. The letters C C indicate the extent of motion allowed to 
the hand-block. 

has not been very satisfactory. The experiment, however, has not 
been decisive upon this mode of treatment." 2 

Fig. 103. 




George F. Shrady's splint. To be applied to the palmar surface of forearm and hand ; the hand 
being deflected toward the ulna. A strip of adhesive plaster encircles the forearm and splint near 
the elbow. A loop is also formed for the ulnar margin of the wrist by passing one end of a strip of 
plaster, three inches in width, between the palmar surface of the wrist and the splint, over on the 
dorsum of the wrist; both ends being then brought around and made adherent to the under surface 
of the splint. Lastly, the hand is secured to the hand-piece by a circle of plaster; the dorsal splint, 
if required, can then be applied in the usual way. Passive motion is made every second or third 
day, by grasping the apparatus at wrist and freeing the hand. 

1 Fauger, London Lancet, May 8, 1847. 

2 Velpeau, Boston Med. Journ., vol. xxxv, p. 213. 



300 FRACTURES OF THE RADIUS. 

Notwithstanding these exceptions, the practice seems to be pretty 
well established among the leading surgeons everywhere to employ 
in the treatment of this fracture the principle of adduction of the 
hand, and always to the attainment of the same purpose, namely, 
rotary extension, by which they hope to retain more securely the lower 
fragment in place. 

The late Henry S. Hewit, of this city, devised a very ingenious 
splint, by which the mobility of the wrist and fingers might be more 
perfectly retained. The following is the description given by himself 
of the apparatus: "The wooden ball grasped by the hand is connected 
by a rod to a slender bar running longitudinally upon the face of the 
splint, and capable of being flexed at any desirable length. The rod 
is attached to the travelling connection by a universal joint, giving 
play to the ball in limited movements of flexion, extension, pronation, 
and supination. The natural tendency is for the patient to make these 



Fig. 104. 



movements, and to perpetually relax and contract the fingers. The 
splint upon the inner surface of the arm is. antagonized by a plain flap- 
splint on the outer surface, extending to the superior border of the 
wrist-joint. This splint has been used for upwards of tw T o years by 
myself and others, particularly by Dr. W. T. White, at the Demilt 
Dispensary, and has given good results." 1 

We come now to consider how far this peculiar treatment, ulnar in- 
clination, is capable of answering the special indications of the case we 
are studying. 

It is assumed, as I have already intimated, that, by bearing the hand 
strongly to the ulnar side, the fragments of the radius are brought 
more exactly into apposition, and more easily and effectually retained ; 
an assumption which supposes two things to have been determined: 
first, that there exists an overlapping of the fragments, either through 
the whole extent of their broken surfaces or especially toward the 
radial side, or that the upper end of the lower fragment is inclined to 
fall against the ulna, or that all of these several conditions coexist; 

1 Hewit, Medical Record, April 1, 1873. 



FRACTURE. 301 

and, secondly, that if such displacements do exist, they can be reme- 
died by this manoeuvre. 

The first of these suppositions seems to have been sufficiently con- 
sidered by all those gentlemen who have particularly examined the 
specimens contained in the various pathological collections, and to 
whose careful investigations I have already frequently adverted. With 
rare exceptions, none of these displacements have been found to exist, 
although, as has been observed, a casual inspection of the arm when 
recently broken would often lead to an opposite conclusion. I do not 
here speak of impaction, which is usually upon the posterior margin, 
if it exists at all. 

In regard to the second supposition, namely, that where such dis- 
placements do exist, a forced adduction will aid in the retention of 
the fragments, I shall have to speak more cautiously, because, so far 
as I know, my opinions have received as yet no public and author- 
itative indorsement. In order that adduction may prove eifective, 
there must be some point upon which to act as a fulcrum. It is of 
no use that we rotate the hand for the purpose of making extension 
unless there can be found a resistance or fulcrum upon which the 
rotary motion may be performed. Such a fulcrum exists, no doubt, 
but to determine its availability we must ascertain its character and 
position. 

It is not in the lower end of the ulna, for the ulna has no point of 
contact with the carpal bones, and when, in the natural state of these 
parts, the hand is inclined to the ulnar side, the lower end of the ulna 
rides freely downwards upon the wrist until arrested by the ligaments 
which unite it with the carpus, or by the capacity of the joint to admit 
of motion in this direction. When the lower end of the radius is 
broken, and the ligaments of the joint are more or less torn, the ulna, 
although thrust downwards much farther perhaps than it could ever 
descend in its normal state, still fails to find a support, and spreading 
wider and wider from the radius as it is thrust farther upon the hand, 
no limit can be given to its progress in this direction. It was thus 
that, in one example already mentioned, I found the ulna carried 
downw T ards one inch or more. 

The resistance will, then, in nearly all cases, be found to be in those 
ligaments which bind the lower fragment to the lower end of the ulna, 
and the ulna to the carpal bones, viz., the radio-ulnar, and the internal 
lateral ligaments, which in the normal state of the parts constitute the 
centre upon which forced adduction expends its power, and which 
still continue to be the point of resistance when the radius is broken. 
But how feeble and uncertain must be a resistance which depends 
solely on these injured ligaments ! And how painful to the patient 
must be an extension sufficient to overcome the action of nearly all 
the muscles of the wrist, w T hich is borne entirely by a few lacerated 
and inflamed fibres ! even in health this position, when forced, cannot 
be endured beyond a few seconds, and it must be difficult to estimate 
the sufferings w T hich the same position must occasion when the liga- 
ments are torn and inflamed. 



302 FRACTURES OF THE RADIUS. 

I am not to be told that surgeons have not intended to advocate this 
extreme practice; that they have never recommended forced adduc- 
tion, but only a moderate and easy lateral inclination, such as can 
be comfortably borne. If they have not, then they should not have 
spoken of making extension by this means. An easy lateral inclina- 
tion has no power to do good so far as extension is concerned, any 
more than it has power to do harm. But the fact is, while a majority 
of surgeons have no doubt used less force than was hurtful, some have 
used more than was useful or safe ; indeed^ the sharpness of the curve 
given to the splints figured and recommended by Dupuytren, Nelaton, 
and others, sufficiently indicates that their distinguished inventors in- 
tended to accomplish by these means a forced and violent adduction. 

Malgaigne, speaking of other means of extension applied to the fore- 
arm, suggested by Godin, Diday, and Velpeau, intended to operate 
only in a straight line, and, alluding especially to the modes devised 
by Huguier and Velpeau, remarks : " Without discussing here the 
comparative value of the two forms of apparatus, I believe that they 
could scarcely be endured by the patients ; and M. Diday tells us that 
in the trials which he has made, the pain produced by the extension 
was so great that he was compelled to renounce it." Which observa- 
tions cannot but apply equally to this plan of extension by adduction 
or to any other which might be adopted. 

After all, it must not be inferred that I have concluded to reject 
this mode of dressing in all of its modifications; for although I am far 
from being persuaded of its utility as a means of extension and reten- 
tion in any case, yet I am not prepared to deny to it some very consid- 
erable value in another point of view 7 ; and when judiciously employed 
it can certainly do no harm. It is, I repeat, for another reason alto- 
gether than the one heretofore assigned, that I would recommend its 
continuance, a reason which I cannot so well explain, or hope to render 
intelligible, except to the practical surgeon. This position throws the 
w r hole lower end of both radius and ulna outwards toward the radial 
margin of the splints, and by keeping the radius more completely in 
view, it enables the surgeon better to judge of the accuracy of the re- 
duction, and to recognize more readily the condition and situation of 
the compresses, etc. This alone I have always considered a sufficient 
ground for retaining the angular splint ; although I have treated a 
great number of arms satisfactorily with the straight splints alone. 

Finally, while surgeons have been seeking to accomplish an indica- 
tion, the existence of which is at least rendered doubtful, and by 
means which appear to me totally inadequate, if it did exist, they have 
probably too often overlooked or regarded indifferently an indication 
which is almost uniformly present, namely, to press forwards the tilted 
fragment by a force applied upon the wrist from behind, and to retain 
it in place by suitable compresses. And I cannot help thinking that 
if they had regarded this as the sole indication in most cases, an indi- 
cation generally so easily accomplished, they would have made fewer 
crooked arms, and have saved their patients much suffering and them- 
selves much trouble. Some of the cases which I have reported in the 



FEACTUEE. 303 

early part of this chapter are intended to illustrate the value of this 
principle. 

In case the ulna is dislocated also, and is imprisoned by the annular 
ligament, circumduction with extension, as practiced by Dr. Moore, 
and heretofore described, will be required. 

It only remains for us to determine the precise form of splint which 
ought to be preferred, and to describe its mode of application. 

The narrow "attelle cubitale" of Dupuytren is inconvenient; nor 
can I give the preference to the curved dorsal splint recommended by 
Nelaton, and employed by Robert Smith, Erichsen, and others. It is 
not to me a matter of entire indifference, in case only one curved splint 
is employed, whether this be applied to the palmar or dorsal surfaces 
of the forearm. Foreign surgeons, so far as I know, have applied this 
splint to the dorsal surface, and the straight splint to the palmar ; 
while American surgeons have adopted almost as uniformly the oppo- 
site rule — to whose practice, in this respect, I acknowledge myself 
also partial. It is to the curved splint rather than to the straight that 
we mainly trust ; not simply, or at all, perhaps, because of its form, 
but because the curved splint is also the long splint. This is the 
splint, therefore, which ought to be the most steady and immovable 
in its position. Now, the very irregularities of surface upon the 
palmar aspect of the forearm and hand, instead of constituting an 
embarrassment, enable us, when the splint is suitably prepared and 
adjusted, to fix it more securely. Moreover, upon it alone, after a 
few days, the surgeon may see fit to rely, and in that case it ought to 
be applied to that surface of the arm which is most tolerant of con- 
tinued pressure. The palmar surface, as being more muscular, and 
as having been more accustomed to friction and to pressure, must nec- 
essarily have the advantage in this respect. The palmar splint termi- 
nating also at the metacarpophalangeal articulations, instead of at the 
wrist, as the short straight splint must do when the hand is adducted, 
enables the hand to be flexed upon its extremity over a hand -block, or 
pad of proper size. Such are the not insignificant advantages which 
we claim for this mode over that pursued by our transatlantic brethren. 

The block, suggested first by Bond, of Philadelphia, is a valuable 
addition, since the flexed position is always more easy for the fingers, 
and in case of anchylosis this position renders the whole hand more 
useful. 

For myself, I am in the habit of preparing extemporaneously a 
splint from a wooden shingle, which I first cut into the requisite shape 
and length ; the length being obtained by measuring from the front of 
the elbow-joint, when the arm is flexed to a right angle, to the meta- 
carpo-phalangeal articulations, the fingers being first flexed. It ought, 
indeed to fall half an inch short of the bend of the elbow, to render it 
certain that it shall make no uncomfortable pressure at this point; and 
the direction to measure with the arm flexed is of sufficient importance 
to warrant a repetition. The breadth of the splint should be in all its 
extent just equal to the breadth of the forearm in its widest part, except 
where it is to receive the ball of the thumb, so that there shall be no 




Author's dorsal splint. 



304 FRACTURES OF THE RADIUS. 

lateral pressure upon the bones. If the splint is of unequal breadth, the 
roller cannot be so neatly applied, and it is more likely to become 
disarranged. Thus constructed, it is to be covered with a sack of cotton 
cloth, made to fit moderately tight, with the seam along its back, and after- 
wards stuffed with cotton batting or with curled hair. These materials 
may be passed in, and easily adjusted, wherever they are most needed, 

from the open extremities of the sack. 
-. While preparing, the splint must be 

^pjjjjjjgjK occasionally applied to the arm until 

H *fS it fits accurately every part of the fore- 

^Hjjl^ ^ _^ __ /lpl|f| arm and hand, only that the stuffing 

Author's palmar splint; right arm. must be more firm a little above the 

lower end of the upper fragment, and 

FIG - 106 - in the hollow of the hand. Between 

these two points there should be little 

or no cotton. The open ends of the 

sack are then to be neatly stitched 

over the ends of the splint, after which 

the splint may be laid directly upon the skin without any intermediate 

compresses or rollers. 

The advantages of this form of splint are easily comprehended. They 
consist in facility and cheapness of construction, accuracy of adapta- 
tion, neatness, permanency, and fitness to the ends proposed. There 
is also no possibility of making painful or injurious pressure upon the 
arteries or nerves which lie upon the front of the wrist. 

The extemporaneous splint recommended by Dr. Isaac Hays, of 
Philadelphia, is very similar, but it lacks the neatness and permanency 
of that which I have now described. 

In all cases it is better to employ, also, at least during the first fort- 
night, a straight dorsal splint, of the same breadth as the palmar splint, 
and of sufficient length to extend from the elbow to the middle of the 
carpus. This should be covered and stuffed in the same manner as the 
palmar splint, except that here the thickest and firmest part of the 
splint must be opposite the carpus and the lower fragment. 

Having restored the fragment to place, in case of Colles's fracture, 
by pressing forcibly upon the back of the lower fragment, the force 
being applied near the styloid apophysis of the radius, the arm is to 
be flexed upon the body, and placed in a position of semi-pronation, 
w T hen the splints are to be applied, and secured with a sufficient num- 
ber of turns of the roller, taking especial care not to include the 
thumb, the forcible confinement of which is always painful and never 
useful. 

Let me repeat that, in most cases, all of our success will depend upon 
whether we employ sufficient force in the early stage of the accident, 
and in the right direction. When once reduced it is easily kept in 
place. 

I cannot too severely reprobate the practice of violent extension of 
the wrist in the efforts at reduction, when no overlapping or impaction 
of the fragments exists and the ulna is not dislocated; and that, whether 
this extension be applied in a straight line, or with the hand adducted. 



FRACTURES OF THE RADIUS. 



305 



Fig, 107. 




It has been shown that in a great majority of cases no indication in 
this direction is to be accom- 
plished; and to pull violently, 
under these circumstances, upon 
the wrist, is not only useless but- 
hurtful. It is adding to the frac- 
ture, and to the other injuries 
already received, the graver path- 
ological lesion of a stretching, 
a sprain of all the ligaments con-, 
nected with the joint. I am per- 
suaded that to this violence, add- 
ed to the unequal and too firm 
pressure of the splints, are, in a 
great measure, to be attributed 
the subsequent inflammation and 
anchylosis in very many cases. 

The first application of the 
bandages ought to be only moder- 
ately tight, and as the inflamma- 
tion and swelling develop in these 
structures with rapidity the band- 
ages should be attentively watched, 
and loosened as soon as they be- 
come painful. It must be con- 
stantly borne in mind that, to pre- 
vent and control inflammation, in 
this fracture, is the most difficult 
and by far the most important object to be accomplished, while to retain 
the fragments in place, when once reduced, is comparatively easy. 

During the first seven or ten days, therefore, these cases demand the 
most assiduous attention ; and we had much better dispense with the 
splints entirely than to retain them at the risk of increasing the inflam- 
matory action. Indeed, I have no doubt that very many cases would 
come to a successful termination without splints, if only the hand and 
arm were kept perfectly still in a suitable position until bony union 
was effected. 

I must also enter my protest against many or all of those carved 
splints which are manufactured, hawked about the country, and sold 
by mechanics, who are not surgeons; with a fossa for each styloid pro- 
cess, a ridge to press between the bones, and various other curious pro- 
visions for supposed necessities, but which never find in any arm their 
exact counterparts, and only deceive the inexperienced surgeon into 
neglect of the proper means for making a suitable adaptation. They 
are the fruitful sources of excoriations, ulcerations, inflammations, and 
deformities. 

In reference to the treatment of these fractures, the following cases 
and the accompanying remarks, by that great surgeon, Dupuytren, are 
too pertinent not to merit a place in every treatise of this character. 

"The two succeeding cases are not only interesting as fractures of 



The author's dressing complete. Th« curved 
palmar splint is not in view, only the dorsal. The 
faint white lines represent the roller. The sling 
is omitted, for the purpose of bringing the other 
dressings into view. 



306 FRACTURES OF THE RADIUS. 

the radius, but they are farther deserving of attentive consideration, on 
account of the serious complications which accompanied them, and 
which were the consequence of forgetting an important precept. More 
than once, indeed, it has occurred that the surgeons have been so intent 
on preserving fractures in their proper position that the extreme con- 
striction employed has actually caused destruction of the soft parts. A 
piece of advice which I have very frequently given, and which I can- 
not too often repeat, is to avoid tightening too much the apparatus for 
fractures during the first few days of its being worn ; for the swelling 
which supervenes is always accompanied by considerable pain, and may 
be followed by gangrene. It cannot, therefore, be too urgently im- 
pressed on young practitioners, to pay attention to the complaints which 
patients make ; and to visit them twice daily, and relax the bandages 
and straps as need may be, in order to obviate the frightful consequences 
which may spring from not heeding this necessary precaution; by care- 
fully attending to this point I have been saved the painful alternative 
of ever having to sacrifice a limb for complications which its neglect 
may entail. 

" Antoine Rilard, set. 44, fractured his right radius whilst going down 
into a cellar, in Feb. 1828, and went at once to the Hospital of La 
Charite. When the fracture was reduced (it was near the base of the 
bone) an apparatus was applied, but fastened too tightly ; and, notwith- 
standing the great swelling and the acute pain which the patient en- 
dured, it was not removed until the fourth day, when the hand was 
cold and oedematous, and the forearm red, painful, and covered with 
vesications. Leeches, poultices, and fomentations were applied, and 
followed by some alleviation of the local symptoms, though there was 
much constitutional disturbance. At the close of a fortnight from the 
accident, the palmar surface of the forearm presented a point where 
fluctuation was supposed to exist ; but when a bistoury was plunged 
into it no matter followed. Portions of the flexor muscles subsequently 
sloughed, and the skin subsequently mortified. The only resource was 
amputation, which was performed above the elbow s'ix weeks after his 
admission ; and he afterwards recovered without the occurrence of any 
further untoward symptoms. 

"R., set. 3(5, was at work boring an artesian well in 1832, when he 
was struck by part of the machinery on the right forearm ; he was in- 
stantly knocked down and thrown violently on the right thigh. A 
surgeon who was sent for detected a fracture of the radius, and applied 
the usual apparatus, consisting of pads and splints, confined by a roller 
extending from the extremities of the fingers to the elbow, which com- 
pressed the arm so tightly as to give rise to very great suffering. The 
fingers, hand, and forearm were numbed almost to insensibility, and 
yet the surgeon in attendance did not think proper to loosen the appa- 
ratus. Such was the condition of the patient until he came to the 
Hotel Dieu, four days after the accident; the fingers were then black, 
cold, and insensible, and when I removed the splints I found the hand 
likewise black, especially on its palmar surface. The lower part of the 
forearm was a shade less livid, but equally cold and insensible; and 
several vesicles filled with pink-colored serum were apparent on both 



FRACTURES OF THE RADIUS. 307 

its surfaces where the splints had pressed ; the upper part of the fore- 
arm was inflamed, swollen, and very painful. He was bled and leeches 
were applied to the inflamed part of the arm ; camphorated spirit was 
applied to the fingers. 

" On the following day heat was restored as low as the wrist, but 
the hand remained for the most part livid and cold, and the radial 
artery did not pulsate. Seventy leeches were applied to the forearm, 
and the local application was continued." On the second day after 
admission thirty more leeches were applied. On the fourth day the 
hand looked a little better, so as to " encourage some hope of its being 
saved; but this was again blighted on the sixth day, by the entire loss 
of heat and sensibility in the part and increased pain and swelling in 
the forearm, to which the gangrene subsequently extended. On the 
twelfth day amputation was performed at the elbow-joint; but the 
patient did not survive the operation more than ten days, the imme- 
diate cause of death being acute pleurisy. There was a considerable 
quantity of purulent serosity poured out on the right side of the chest; 
and abscesses were found in the lungs and liver. On examining the 
arm, there was found to be a simple fracture of the radius about its 
centre. 

" The above case presents a painful illustration of the neglect to 
which I have alluded. In nearly every instance the swelling of the 
limb requires that careful attention should be paid to the bandage or 
straps, by which the apparatus is confined. Similar accidents are 
likely to result from the employment of an immovable apparatus, of 
which an example occurred in the practice of M. Thierry, one of my 
pupils. He was summoned to visit a young girl, on whom such an 
apparatus had been applied for supposed fracture of the radius. After 
suffering excruciating torment, the forearm mortified, and amputation 
was the only resource; on examining the limb no trace of fracture 
could be discovered. Had a simple apparatus been here employed, 
and properlv watched, this patient's limb would not have been sacri- 
ficed/' 1 

Robert Smith mentions, also, the case of a boy, set. 18, who had a 
fracture of the lower extremity of the radius, through the line of the 
junction of the epiphysis with the diaphysis, caused by being thrown 
from a horse. A surgeon applied, within an hour, a narrow roller 
tightly around the wrist. On the following day the limb was intensely 
painful, cold and discolored; still the roller was not removed, nor even 
slackened. On the fourth day he was admitted into the Richmond 
Hospital, when the gangrene had reached the forearm. Spontaneous 
separation of the soft parts finally occurred, and the bones w T ere sawn 
through twenty-four days after the fracture was produced, from which) 
time " everything proceeded favorably." 2 

Nov. 21, 1851, a boy, ten years old, living in the town of Andover, 
Mass., had his left hand drawn into the picker of a woollen mill, pro- 

1 Dupuytren, Injuries and Diseases of Bones, S} T d. ed., London, 1847, pp. 145-7. 

2 K. Smith, Treatise on Fractures, etc., Dublin, 1854, p. 170. 



308 FRACTURES OF THE RADIUS. 

ducing several severe wounds of the hand and a fracture of the radius 
near its middle. One of the wounds was situated directly over the 
point of fracture, but whether it communicated with the bone or not 
was not ascertained. A surgeon was called, who closed the wounds, 
covered the forearm with a bandage from the hand to above the elbow, 
and applied compresses and splints. This lad made no complaint, his 
appetite remaining good and his sleep continuing undisturbed, until 
the third day, when he began to speak of a pain in his shoulder; on 
the same day also it was noticed that his hand was rather insensible to 
the prick of a pin. Early on the morning of the fourth day his sur- 
geon being summoned, found him suffering more pain and quite rest- 
less; and on removing the dressings, the arm was discovered to be in- 
sensible and actually mortified from the shoulder downwards. 

Opiates and cordials were immediately given to sustain the patient, 
and fomentations ordered. 

On the sixth day a line of demarcation commenced across the shoulder, 
and on the twenty-first day the father himself removed the arm from 
the body by merely separating the dead tissues with a feather. Subse- 
quently a surgeon found the head of the humerus remaining in the 
socket, and removed it, the epiphysis having become separated from 
the diaphysis. The boy now rapidly got well. 

In the year 1853 this case became the subject of a legal investiga- 
tion, in the course of which Dr. Pilsbury, of Lowell, Mass., declared 
that in his opinion this unfortunate result had been caused by too 
tight bandaging, and by neglecting to examine the arm during four 
days. 

On the other hand, Drs. Hayward, Bigelow, Townsend, and Ains- 
worth, of Boston, with Kimball, of Lowell, Drs. Loring and Pierce, 
of Salem, believed that the death of the limb was due to some injury 
done to the artery near the shoulder-joint; and in no other way could 
they explain the total absence of pain during the first two days ; nor 
could they regard this condition as consistent with the supposition that 
the bandage occasioned the death of the limb. 1 

I cannot but think, however, that these gentlemen were mistaken, 
and that the gangrene was alone due to the bandages. In a similar 
•case which came under my own observation, and in which both the 
radius and ulna w T ere broken, the roller extended no higher than just 
above the elbow, and the patient complained of no pain until the band- 
ages were unloosed, yet the arm separated at the shoulder-joint. I 
shall refer again to this example in the chapter on fractures of the 
radius and ulna; and I shall take occasion then also to speak more 
fully of the causes of these terrible accidents. 

Norris mentions another case of compound fracture of the lower end 
of the radius which came under his notice at the Pennsylvania Hospital 
in August, 1837, the arm having been dressed by a surgeon within 
half an hour after the accident, with bandages and splints. When 
these bandages were removed at the hospital, on the fifth day, " the 

1 Bost. Med. and Surg. Journ., vol. xlviii, p. 281. 



PRACTURES OF THE RADIUS. 309 

soft parts around the fracture were found to have sloughed, an abscess 
extended up to the elbow-joint, and sloughs existed over the condyle. 
Severe constitutional symptoms arose, making amputation of the arm 
necessary." 1 

A lady, set. 50, was also seen by Thierry, who, having broken the 
radius near its lower end, lost her fingers by the sloughing consequent 
upon a tight bandage. 2 

A woman was admitted into one of Dr. Wood's wards in the Belle- 
vue Hospital about the 1st of February, 1863, who had fallen upon 
her hand a few days before and broken the radius just above the wrist. 
Her arm was dressed with splints and bandages at one of the dispensa- 
ries in this city. Gangrene ensued, and when I saw her on the 8th of 
February, the death had extended to the middle of the forearm, the 
dead tissues being dry and black. Dr. Wood amputated the arm, but 
she died. 

The remarks which have now been made in relation to the treatment 
of Colles's fracture, are applicable, with only such slight modifications 
as would naturally be suggested, to fractures of the lower end of the 
radius commencing upon the radial side of the bone and extending 
obliquely dow T n wards into the joint; and it is to this form of fracture 
especially, that the pistol-shaped splint must be found applicable. If 
the fracture actually extends into the joint, it must not be forgotten 
that, in order to the prevention of anchylosis, the wrist should be early 
subjected to passive motion. 

The following example of a compound comminuted fracture of the 
radius may serve to illustrate the value of a somewhat novel mode of 
treatment under certain circumstances : t 

William Croak, of Buffalo, set. 30. January 29, 1856, a large piece 
of iron casting fell upon his arm, crushing and lacerating the wrist, 
and comminuting the lower part of the radius; he was immediately 
taken to the Hospital of the Sisters of Charity. I found the whole of 
the soft parts torn away in front of the joint, and the fragments of the 
radius projected into the flesh in every direction. The hope of saving 
the hand seemed to be scarcely sufficient to warrant the attempt; at 
least by the ordinary mode of procedure. I, however, stated to the 
gentlemen present, among whom were Dr. Rochester, my colleague, 
and the house surgeon, Dr. Lemon, that I believed it could be saved 
if, having removed the fragments of the radius, we practiced resection 
of the lower end of the ulna, and allowed the muscles to become com- 
pletely relaxed. Accordingly, after placing my patient under the in- 
fluence of chloroform, I enlarged the wounds so as to enable me to re- 
move six or seven fragments of the radius, leaving others which were 
broken off* but not much displaced. I then removed with the saw one 
inch and a half of the lower end of the ulna. The hand was immedi- 
ately drawn up by the contraction of the remaining muscles, but their 
tension was completely relieved. 

1 Norris, note to Liston's Surgery, p. 54. 

2 Amer. Journ. Med. Sci., vol. xxv, p. 461, from L'Experience for 1838. 



310 



FRACTURES OF THE RADIUS. 



Fig. 108. 




The wounds were closed and dressed lightly, and the whole limb was 
placed on a broad and well-padded splint covered with oiled cloth. 
The hand, which was very pale and exsanguine, was cov- 
ered with warm cotton batting. 

The subsequent treatment was changed from time to 
time to suit the indications; but his recovery was rapid and 
complete, nor was there at any time excessive inflammation 
in any part of the limb. 

I have seen this man frequently since he left the hospi- 
tal, and while he has recovered only a little motion in the 
wrist-joint, his hand and fingers are nearly as useful as be- 
fore the accident. He is able to perform all ordinary kinds 
of labor with almost as much ease as most other men; and 
what is always gratifying to the humane surgeon, he does 
not fail to appreciate fully the service which has been con- 
ferred upon him by the preservation of his somewhat mu- 
tilated hand. 

I have recently adopted the same treatment with equal 
success in a case of gunshot wound of the lower end of the 
radius. 

Epiphyseal Separations, — This bone is formed from three 
centres, namely, one for the shaft and one for either ex- 
tremity. The shaft is ossified at birth. About the end of 
the second year ossification commences in the lower epiphy- 
sis, and it becomes united to the shaft at about the twen- 
tieth year. The same process commences in the upper 
epiphysis at about the fifth year, and is completed by con- 
solidation with the shaft at the age of puberty. 
I have met with no recorded examples of separation of the upper 
epiphysis, and the examples of separation of the lower epiphysis have 
seldom been clearly made out. I have already mentioned one as 
having been reported by Robert Smith. He speaks also of other cases 
occurring in conjunction with a separation of the lower end of the ulna, 
and which is very liable to be mistaken for a dislocation. 1 

The treatment of this accident will not require any special considera- 
tion, since it will not differ essentially from the treatment required in 
a fracture occurring at the same point. 




Radius with 

epiphyses. 

(From Gray.) 



1 Robert Smith, op. cit., p. 164. 



FRACTURES OF THE ULNA. 



311 



CHAPTER XXII. 



FRACTURES OF THE ULNA. 



I 1. Shaft of the Ulna. 

Causes. — The shaft of the ulna, when it alone is the seat of fracture, 
is generally broken by a direct blow. I have never seen an excep- 
tion to this rule ; but Yoison has related in the Gazette Medicale for 
1833 a single exception, in which it was said to have been broken by 
a fall upon the palm of the hand. Malgaigne thinks it is most often 
broken when one seeks to ward oif a blow with the arm ; but it has 
happened most often to me to see it broken by a fall upon the side of 
the arm. 

Point of Fracture, Direction of Displacement, etc. — In an analysis of 
thirty-three cases, I find the shaft has been broken eleven times in 
its upper third, twelve times in its middle third, and ten 
times in its lower third. All portions seem, therefore, fig. 109. 
to be about equally liable to fracture. I think, also, the 
fractures have generally been oblique. 

Contrary to what has been observed by other writers, 
I have noticed that no law prevailed as to the direction 
in which the fragments have become displaced; the 
broken ends being found directed forwards, backwards, 
inwards, or outwards, according to the direction of the 
blow which has occasioned the fracture; and this is in 
accordance with the general rule in other fractures 
occasioned by direct blows. No doubt, however, other 
things being equal, the tendency of the lower fragment 
would be toward the interosseous space, in consequence 
of the action of the pronator quadratus in this direction; 
while the upper fragment, owing to its broad and firm 
articulation at the elbow-joint, can only be displaced 
forwards or backwards, at least to any great extent. 

Complications. — In no case of the shaft of a long bone 
have I found serious complications more frequent than 
in fractures of the shaft of the ulna. Four have been 
compound ; eleven complicated with a forward, or for- 
ward and outward dislocation of the head of the radius; Fracture of the 
one with a partial dislocation of the knver end of the shaft of the ulna - 
radius backwards ; and one with a dislocation of both 
radius and ulna backwards at the elbow-joint. It will be seen, there- 
fore, that sixteen, or nearly one-half of the whole number, have been 
seriously complicated. 

Symptoms. — Occasionally this fracture is found to exist without sen- 



312 FRACTURES OF THE ULNA. 

sible displacement. In such cases the diagnosis is sometimes difficult, 
and can only be determined by the crepitus and mobility. If, how- 
ever, the ulna is firmly seized above and below the point which has 
suffered contusion, and pressed in opposite directions, these signs will 
generally be sufficiently manifest, and will render the diagnosis certain. 

But in cases where there is considerable displacement, the inner 
surface of the bone is so superficial as to enable us to detect its devi- 
ations with the eye alone, or, when swelling has already occurred, by 
the fingers carried firmly and slowly along this margin. 

If the head of the radius is dislocated also, the displacement of the 
broken ends of the ulna must always be considerable, and the con- 
sequent deformity palpable. I have known one instance, however, in 
which a surgeon living in the neighboring province of Upper Canada 
recognized and reduced a dislocation of the radius and ulna backwards, 
but did not detect a fracture of the ulna two inches above its lower 
end. Six months after, in the month of March, 1856, the patient 
called upon me with a marked deformity near the wrist, occasioned by 
the backward projection of the broken ulna, and with a complete loss 
of the power of supination. It will not surprise us that this fracture 
was overlooked when we learn that the man had fallen fifty-five feet. 

Prognosis. — In simple fractures the prognosis is generally favorable, 
since no overlapping can occur, and the lateral displacements are not 
usually sufficient to produce a marked deformity, or to interfere materi- 
ally with the functions of the arm ; yet it is not unfrequent to find the 
fragments inclining slightly forwards or backwards, inwards or out- 
wards. If the fragments fall toward the radius, I have noticed in 
three or four instances a slight projection of the lower end or styloid 
process of the ulna to the ulnar side; but not interfering in any degree 
with the motions of the wrist-joint. 

I have seen the radius left unreduced nine times after a fracture of 
the ulna, and in each example the forearm was shortened. A boy, set. 
17, was struck by a locomotive, and severely injured in various parts 
of his body, June 5, 1855. I saw him, with two very intelligent coun- 
try practitioners, a few hours after the accident. The whole left arm 
was then greatly swollen. Crepitus was distinct, and we easily recog- 
nized the fracture of the ulna about three inches below its upper end, 
with which an open wound was in direct communication. We sus- 
pected, also, a dislocation of the head of the radius forwards, but as we 
could not make ourselves certain, and finding that the arm was in such 
a condition as to preclude any further manipulation without greatly 
diminishing the chance of saving the limb, we made no attempt at re- 
duction, but laid the arm upon a pillow and directed cool water lotions. 

At no subsequent period, in the opinion of the medical gentleman 
who was left in charge, did a favorable opportunity occur to reduce 
the radius; and at the end of two months I found the ulna united, 
with the fragments bent forwards and outwards toward the radius, 
while the head of the radius lay in front of the humerus. The forearm 
was shortened three-quarters of an inch. He could flex his arm freely 
to a right angle and a little beyond ; and he could straighten it per- 



SHAFT OF THE ULNA. 313 

fectly. Hand slightly pronated, with partial loss of supination. Whole 
arm nearly as strong and as useful as before the accident. 

The second case occurred in the person of a man set. 26, residing 
about twenty miles from town, and was occasioned by the kick of a 
horse. This was also a compound fracture. It does not appear that 
his surgeon discovered the dislocation of the radius, but supposed that 
it was a fracture of both bones. On the ninth day the patient became 
dissatisfied and dismissed his surgeon, but employed no other. 

Oct. 1, 1849, eleven weeks after the accident, he called upon me. 1 
found the ulna united, with a manifest displacement, but I could not 
discover that there had been any fracture of the radius. The head of 
the radius was in front of the external condyle, and a depression ex- 
isted where it formerly articulated. When the arm was flexed, the head 
did not strike the humerus so as to arrest the flexion, but it glided up- 
wards and outwards along the inclined base of the external condyle. 
He had already begun to use his arm considerably in labor. The forearm 
was shortened one inch. 

Three times I have noticed after the lapse of several years that the 
forearm could not be perfectly supinated ; but pronation was never 
permanently impaired. I think, also, that the motions of flexion and 
extension have always, except where the radius has remained dislo- 
cated, been completely restored soon after the splints were removed ; 
and even in these latter cases it is only extreme flexion which has been 
hindered. • 

Treatment. — In simple fracture we must look carefully to the lateral 
deviation of the fragments; and if they are found to be salient forwards 
or backwards, pressure made directly upon or near their extremities 
restores them to place, but it often requires considerable force to ac- 
complish this. A gentleman fell and broke the right ulna near its 
middle. He came immediately to me, and I found the fragments dis- 
placed backwards. Pressing strongly with my fingers they sprung 
forwards with a distinct crepitus, and I thought they were now in 
exact line. A broad and well-padded splint was applied to the fore- 
arm, and I took especial pains with compresses nicely adjusted, from 
day to day, to keep everything in place. The arm was placed in a 
lling. Eight months after the accident this gentleman died of cholera, 
ancfl was°permitted to dissect the arm. I found the fragments well 
united, but with a very palpable projection of the fragments backwards, 
in the direction in which they were at first. _ 

If the displacement is in the direction of the radius it is^more diffi- 

j cult to overcome, but its necessity is much more urgent, since, if the 

fragments fall completely against the radius, a bony union may take 

place, occasioning a complete loss of the power of pronation and of 

supination. . 

While moderate extension is being made, and the hand is well supi- 
nated, the fingers of the surgeon should be pressed firmly, and in spite 
sometimes of the complaints of the patient, between the radius and 
ulna, and the fragments of the broken ulna fairly pushed out from the 

radius. . , „ 

The forearm may now be laid in the usual position against the iront 

21 



314 FRACTURES OF THE ULNA. 

of the chest, midway between supination and pronation, and the same 
splints applied and in the manner which we shall hereafter describe for 
fractures of the shaft of both bones. 

We ought, however, especially to bear in mind the danger of thrust- 
ing the fragments against the radius, by allowing the sling or the 
bandage to rest against the middle of the ulnar side of the bone. To 
prevent this the sling ought to support the arm by passing only under 
the hand and wrist, or the forearm may be laid in a firm gutter, which 
will touch the forearm only at the elbow and wrist, or it may be laid 
upon its back, as suggested and practiced by Scott, and also by Fleury, 
the latter of whom, according to Malgaigne, had a case which had been 
treated in the position of semi-pronation, and which remained not only 
displaced, but refused to unite; but when the arm was supinated the 
fragments came at once into contact, and bony union speedily took 
place. This position may be adopted whenever it is found to be prac- 
ticable ; but the position of semi-pronation is generally much more 
comfortable to the patient, at least when the forearm is laid across the 
chest, and I have found very few patients who would submit to a po- 
sition of complete supination. 

In fractures accompanied with dislocation of the head of the radius 
forwards or backwards, nothing should prevent the immediate reduc- 
tion of the dislocation but a demonstration of its impossibility, or a 
condition of the limb which would render manipulation hazardous. 
It can be reduced, generally, by pushing forcibly upon the head of the 
bone in the direction of the socket, while the arm is moderately flexed 
so as to relax the biceps, and while extension is being made at the 
forearm by an assistant. In making the counter-extension, care should 
be taken to seize the lower end of the humerus by the condyles, rather 
than by its anterior- aspect, by which precaution we shall avoid press- 
ing upon and rendering tense the tendon of the biceps. 

July 29, 1845, a lad, set. 9, fell from his bed, breaking the ulna and 
dislocating the head of the radius. Dr. Austin Flint was called on 
the following morning, and at his request I was invited to see the pa- 
tient with him. We found the ulna broken obliquely near its middle, 
and the head of the radius dislocated forwards. While Dr. Flint seized 
the elbow in front of the condyles, I made extension from the hand, 
the forearm being slightly flexed upon the arm, and at the same moment 
I pushed forcibly the head of the radius back to its socket. The re- 
duction was accomplished easily and completely. 

We then dressed the arm with an angular splint, constructed with 
a joint opposite the elbow. This was laid upon the palmar surface, 
and the whole was nicely padded, especially in front of the head of 
the radius. In two weeks pasteboard was substituted for the angular 
splint. At the end of six weeks I was permitted to examine the arm, 
and found the head of the radius perfectly in place, but the points of 
fracture slightly salient. All of the motions of the arm were fully 
restored. 

June 2, 1845. C. C, set. 9, fell upon his arm, breaking the ulna 
obliquely near its middle, and dislocating the head of the radius for- 
wards. Dr. J. P. White being called, requested me to visit the patient 



COHONOID PROCESS OF THE ULNA. 315 

also with him. We found one of the broken fragments protruding 
through the skin, on the inside of the arm. 

With great ease, and by simply pressing with considerable force 
upon the head of the radius, it was made to slide into its socket. The 
case was left in charge of Dr. White. 

Five weeks after, I found all of the motions of the forearm com- 
pletely restored, except that he could not extend it perfectly. The 
head of the radius was also a little more prominent in front than in 
the opposite arm. 

Four or five years later, the projection of the head of the radius had 
disappeared, and the functions of the arm were perfect. 

§ 2. Coronoid Process of the Ulna. 

Dissections have established the possibility of this fracture as a sim- 
ple accident in the living subject ; but I have not myself seen any 
example of which I can speak positively. In the two following cases, 
the existence of such a fracture was at first suspected, but I have now 
very little doubt but that my diagnosis was incorrect. I shall relate 
them, however, as examples of those accidents which are likely to be 
mistaken for fracture of this process. 

A laboring man, aged about twenty-five years, had been seen and 
treated by another surgeon, for what was supposed to be a simple dis- 
location of the radius and ulna backwards. The surgeon thought he 
had reduced the dislocation very soon after the accident. On the fol- 
lowing day he found the dislocation reproduced, and he requested me 
to see the patient with him. The arm was then much swollen, but the 
character of the dislocation was apparent. By moderate extension, 
applied while the arm was slightly flexed, and continued for a few 
seconds, reduction was again effected, the bones returning to their 
places with a distinct sensation ; but on releasing the arm the disloca- 
tion was immediately reproduced. These attempts to reduce and re- 
tain in place the dislocated bones were repeated several times during 
this day, and on subsequent days, but to no purpose, and the patient 
was dismissed after about two weeks with the bones unreduced. 

The impossibility of retaining the bones in place, and the existence 
of an occasional crepitus during the manipulation, inclined me to be- 
lieve at the time that the dislocation was accompanied with a fracture 
of the coronoid process. 

Another similar case has since presented itself in a child nine years 
old, and in which the subsequent examinations not only demonstrated 
the non-existence of a fracture, but also rendered doubtful the justness 
of the conclusions which I had drawn in the case just related. 

This lad fell, November 4, 1855, and his parents immediately brought 
him to me ; but as he lived many miles from town, I did not see him 
until eighteen hours after the injury was received. I found the arm 
much swollen, slightly flexed, and pronated. Flexion and extension 
of the arm were very painful, the pain being referred chiefly to the 
front of the joint, near the situation of the coronoid process ; and at 
this point also there was a discoloration of the size of a twenty-five 



316 FRACTURES OF THE ULNA. 

cent piece. Flexing the forearm moderately upon the arm and making 
extension, the bones came readily into place, but without sensation of 
any kind, either a snap or a crepitus. That the bones had now resumed 
their position, however, I made certain by a very careful examination 

Fig. 110. 




Fracture of the co conoid process. 

with the hand and by measurement, yet they would not remain in place 
one moment when the extension was discontinued. The reduction was 
made several times, and constantly with the same result. We then 
applied a right-angled splint to the arm, having first reduced the bones, 
and thus were able to retain them in position. I believed that the 
coronoid process was broken, and so informed the surgeon to whose 
care the boy was returned. 

Five months after, he was brought again to me, and I then found 
that the radius and ulna had been kept in place ; the motions of the 
joint were perfect, and if the coronoid process had ever been broken it 
was now again in its natural position, and with every structure about it 
in a condition as complete as it was before the accident. For myself, 
I do not believe that so perfect a union of this process can happen ; at 
least in a case where, as must have been the fact in this example, the sep- 
aration and displacement of the process are such that it no longer offers 
an obstacle to the dislocation of the ulna backwards and upwards. 

Malgaigne thinks that the fracture is more frequent than the small 
number of reported examples would lead us to suppose, especially be- 
cause he has noticed how often the summit of the process is broken off, 
when dislocation of the radius and ulna backwards is produced artifi- 
cially on the dead subject. In three or four cases, also, of dislocations 
of these bones backwards and inwards, which had come under his notice, 
he was unable to feel this process, and he therefore thought it probable 
that it was broken off. Other surgeons have thought, also, that it was 
a not infrequent accident ; and they have constantly made use of this 
supposition to explain those cases in which the radius and ulna having 
been dislocated backwards, would not afterward remain in place when 
well reduced. Fergusson has indeed made the extraordinary statement 
in relation to dislocations of the radius and ulna backwards generally, 
that in these cases "the coronoid process will probably be broken. " 

But, in my opinion, these fractures are exceedingly rare; and I think 
these gentlemen need to have furnished some more conclusive evidence 
of the correctness of their opinions than can be found in their writings, 
or in the writings of any other surgeons which I have seen. 

Malgaigne mentions three reported examples, namely : one published 
by Combes Brassard, an Italian surgeon, in 1811, which Brassard saw 
only after a lapse of three months ; one seen by Pennock, and published 
in the Lancet in 1828, the patient then being sixty years old, and the 
accident having occurred when he was a young man ; the third was 






CORONOID PROCESS OF THE ULNA. 317 

seen by Sir Astley Cooper, several months after the accident, and is 
reported by himself in his excellent treatise on Fractures and Disloca- 
tions. Says Sir Astley : " It was thought, at the consultation which 
was held about him in London, that the coronoid process was detached 
from the ulna." This Avas the only living example seen by Sir Astley 
in his long and immensely varied surgical practice; and even here we 
cannot fail to notice the apparent reserve with which he expresses 
his opinion — " It was thought at the consultation." 

To these examples our own researches have added a few others. 

Dorsey says that Dr. Physick once saw a fracture of the coronoid 
process. The symptoms resembled a luxation of the forearm back- 
wards, " except that when the reduction was effected, the dislocation 
was repeated, and by careful examination, crepitation was discovered. 
The forearm was kept flexed at a right angle with the humerus. The 
tendency of the brachialis interims to draw up the superior fragment 
was counteracted in some measure by the pressure of the roller above 
the elbow. A perfect cure was readily obtained." 1 In 1830, Dr. Wil- 
liam M. Fahnestock reported a case occurring in a boy, who, having 
fallen from a haymow, received the whole weight of his body " on the 
back part of the palm of the left hand," while the arm was extended 
forwards. It seemed to be a dislocation of the forearm backwards, 
but when reduced it was again immediately displaced, with an evident 
crepitus. The arm was secured in the angular splint of Dr. Physick 
and "recovered very speedily." 2 Dr. Couper, of the Glasgow Infirm- 
ary, also has reported a dislocation of the forearm backwards and out- 
wards, occurring in a young man aged seventeen, and which he thinks 
was accompanied- with this fracture. The dislocation was easily re- 
duced, but returned again immediately on ceasing the extension. The 
fragment was not felt, nor does he speak of crepitus ; the existence of 
the fracture being inferred from the fact that the bones would not re- 
main in place without help. The forearm was placed across the chest, 
with the fingers pointing toward the opposite shoulder, and secured in 
this position with splints and a bandage. At the end of four weeks 
union had taken place, with only slight deformity, although with some 
stiffness of the joint. 

In relation to this example, the editor remarks that the symptoms 
were not to his mind conclusive in determining the existence of a frac- 
ture of the coronoid process, and he inclines to the belief that it was 
rather an oblique fracture of the lower extremity of the humerus. 
" In cases like these," he adds, " where very rare accidents are sus- 
pected, we think that unless the diagnosis is clear, the leaning should 
always be the other way : we mean that, cceteris paribus, the symptoms 
should rather be referred to the common than the extraordinary injury. 
The contrary practice introduces a dangerous laxity in diagnosis." 3 

Dr. Duer, of Philadelphia, has reported a case which occurred in a 

1 Dorsey, Elements of Surgery, vol. i, p. 152. Philadelphia, 1813. 

2 Fahnestock, Amer. Journ. Med. Sci., vol. vi, p. 267. 

3 Couper, Lond. Med.-Chir Rev., new ser., vol. xi, p. 509. 



318 FRACTURES OF THE ULNA. 

boy six years old, and in which he felt and moved the fragment with 
his fingers. It was complicated with a dislocation, which remains un- 
reduced. This case was last seen about seven weeks after the accident. 1 
If at a later period we could be permitted to examine the patient, it is 
probable that the diagnosis might be rendered certain. 

In the American Medical Monthly for October, 1855, also, I find the 
report of a trial for malpractice, in which a lad nine years old received 
some injury about the elbow-joint which resulted in a maiming. The 
defendant claimed that there had been a dislocation of the forearm 
backwards, accompanied either with a fracture of the trochlea of the 
humerus, or of the coronoicl process of the ulna. 

Dr. Crosby, of Dartmouth College, testified that he had never met 
with a fracture of this process, yet he would not say that it did not 
exist in this case. He was not able to decide positively. Dr. Peaslee, 
of the same college, thought it altogether probable that it had been 
broken, and Dr. Spaulding was of the opinion fully that it had been 
broken. 

The jury did not agree, and a nonsuit was finally allowed by the 
court. 

The defendant, in his report of the trial, seems to me to have justly 
complained that Mr. Fergusson has said, that in a dislocation of the 
forearm backwards " the coronoid process will probably be broken." 
This was urged in the trial by the plaintiff's counsel as contradicting 
the medical testimony, and as evidence of a conspiracy on the part of 
the surgeons to defeat the ends of justice ; since they constantly affirmed 
that the accident was so rare as not to have been reasonably expected, 
and that a failure to look for or to discover it did not imply a lack of 
ordinary skill or care. 2 

Says Mr. Liston : " The coronoid process is occasionally pulled or 
pushed off from the shaft, more especially in young subjects. I saw a 
case of it lately, in which the injury arose in consequence of the pa- 
tient, a boy of eight years, having hung for a long time from the top 
of a wall by one hand, afraid to drop down ;" 3 after whom Miller, 
Erichsen, Skey, Lonsdale, and most of the Scotch and English sur- 
geons have repeated the assertion that this process may J)e broken in 
this manner by the action of the brachialis anticus alone, yet no one 
of them has to this day seen another example. 

The explanation of the accident in the case of the boy, given by 
Liston, implies two anatomical errors : first, that the coronoid process 
is an epiphysis during childhood ; and second, that the brachialis anti- 
cus is inserted upon its summit. The coronoid process is never an 
epiphysis, but is formed from a common point of ossification with the 
shaft ; the olecranon process and the lower extremity of the ulna having 
also separate points of ossification : the olecranon becoming united to 
the shaft at the sixteenth year, and the lower epiphysis at the twentieth. 
Moreover, the brachialis anticus has its insertion at the base of the 

1 Duer, Amer. Journ. Med. Sci., Oct. 1863, p. 390. 

2 Op. cit, vol. iv, p. 339. 3 Liston, Practical Surgery, p. 55. 



COEONOID PROCESS OF THE ULNA. 



319 



Fig. 111. 



process and partly upon the body of the ulna, but in no part upon its 
summit ; indeed, the process seems rather to be intended as a pulley 
over which the brachialis anticus may play ; resembling 
also somewhat, in its function, the patella ; serving to 
protect the joint and perhaps the muscle itself from be- 
coming compressed in the motions of the joint. Cer- 
tainly it could never have been broken by the action of 
this muscle, and the case mentioned by Mr. Liston 
must find some other explanation. It may have been a 
rupture of the brachialis anticus itself, or of the biceps, 
or possibly a forward luxation of the head of the radius. 
Either of these suppositions is more rational than the 
statement made by Mr. Liston, because either one of 
them is possible, while his supposition is impossible. 

I have already quoted Dr. Hodges as saying that he 
had found the coronoid process broken off three times 
in connection with longitudinal fractures of the head of 
the radius. 

These, if I except my own, constitute all of the sup- 
posed examples seen in the living subject, of which I 
find any record ; twelve in all. 

It is true, however, that at least two other cases have 
been reported to me by letter, of which the writers speak 
with great confidence, and the authenticity of which I 
am unable to dispute; but in neither case is the testimony 
to me satisfactory, and as they are not upon record, I 
shall be excused from discussing their merits. 

The two first of the twelve above enumerated, w r ere 
not entirely satisfactory to Malgaigne ; the third is spoken of cautiously 
by Sir Astley Cooper, as if it needed, in addition to his own great name, 
the indorsement of the " London council." Dorsey reports his case upon 
hearsay, and the result is quite too satisfactory to give it much claim to 
credibility. Fahnestock's case is to our mind far from being fully 
proven. Couper's case is doubted by Dr. Johnson ; and the New Hamp- 
shire case was not made out satisfactorily to either the jury or the medi- 
cal men. Liston's case was simply impossible. Duer's case could have 
been better verified at a later period. Having never seen a report of the 
three cases referred to by Dr. Hodges, I am unable to form any opinion 
as to their claims. His well-known reputation, however, disposes me 
to accept of them as authentic. 

Certainly it is not upon such testimony as this that we can rely to 
sustain Mr. Fergussoiv's opinion that this fracture is likely to occur in 
all dislocations of the forearm backwards, or of Malgaigne's conjecture 
that it is of more frequent occurrence than the published cases would 
seem to show. Nor will it be regarded as conclusive, that the beak of 
the process is often found broken after luxations made upon the sub- 
ject ; since between luxations thus produced and luxations occurring in 
the living subject there exists this important difference, that in the case 
of the latter, muscular action is the principal agent in the production 



Ulna, "with epiphy- 
ses. (From Gray.) 



320 FRACTURES OF THE ULNA. 

of the dislocation, while in the former it is the external force alone 
which drives the bone from its socket. 

The fact, therefore, that so few cases have ever been reported, and 
that most of these are far from having been clearly made out, remains 
presumptive evidence that the actual cases are exceedingly rare ; but if 
to this we add such negative evidence as is furnished by actual dissec- 
tions, and by examinations of the pathological cabinets of the world, 
we think the testimony is almost conclusive. 

Only four specimens have been mentioned by any of the surgical 
writers known to me. Sir Astley Cooper says that a person was brought 
to the dissecting-room at St. Thomas's Hospital, who had been the sub- 
ject of this accident. " The coronoid process, which had been broken 
off within the joint, had united by a ligament only, so as to move 
readily upon the ulna, and thus alter the sigmoid cavity of the ulna 
so much as to allow in extension that bone to glide backwards upon 
the condyles of the humerus." 1 Mr. Bransby Cooper adds in a note 
that the external condyle of the humerus was also broken and* united 
by ligament. 

Samuel Cooper describes, rather obscurely, a specimen contained in 
the University College Museum, a in which the ulna is broken at the 
elbow, the posterior fragment being displaced backwards by the action 
of the triceps ; the coronoid process is broken off; the upper head of 
the radius is also dislocated from the lesser sigmoid cavity of the ulna, 
and drawn upwards by the action of the biceps. In this complicated 
accident, the ulna is broken in two places." 

Malgaigne says that Velpeau has also established by an autopsy the 
existence of a fracture of the coronoid apophysis, but without having 
given any further particulars in relation to the case. 

In addition to these examples, Dr. Charles Gibson, of Richmond, Va., 
has stated to me, by letter, that he has in his possession a specimen of 
this fracture, evidently belonging to an adult. The process was broken 
transversely near its extremity, and has united again quite closely and 
without any displacement, and without ensheathing callus. 

We must subject these specimens to analysis also. The first two 
were complicated with other fractures, and the second, especially, seems 
to have been a general crushing of all the bones concerned in the for- 
mation of the elbow-joint; neither of them could have been occasioned 
by contractions of the brachialis anticus, while only that one described 
by Sir Astley Cooper could have been the result of a dislocation of the 
forearm backwards. Of the specimen said to have been seen by Vel- 
peau, I am unable to speak without more circumstantial knowledge of 
its condition. Nor can I speak very confidently of that belonging to 
my distinguished friend, Dr. Gibson, of Virginia. Notwithstanding 
the respect which I entertain for his opinion, I cannot avoid a suspicion 
that the bone was never broken at all, since I find it more easy to be- 
lieve that he is deceived by certain appearances, than that it should 
have united by bone again, and so perfectly as not to leave any line of 
separation or degree of displacement. Certainly the fracture was too 



1 Sir A. Cooper, Dislocations and Fractures, p. 411. 



CORONOID PROCESS OF THE ULNA. 321 

high to have been produced by the action of the muscle, if such a thing 
were ever possible ; and if broken by a dislocation, which must have 
forced it violently from its position, as the ulna was driven upwards, it 
is to me incredible that it should ever be made to unite again so per- 
fectly. 

We are therefore left as before, with no evidence that the coronoid 
process was ever broken by the action of a muscle, and with only one 
example in which it is probable that a fracture occurred as a conse- 
quence of a dislocation of the radius and ulna backwards. If then it 
does happen that in this dislocation it is pretty often found difficult or 
impossible to retain the bones in place without aid, it will be the part 
of prudence to ascribe this troublesome circumstance to some more com- 
mon accident than a fracture of the coronoid process ; perhaps to a frac- 
ture of some portion of the lower end of the humerus, or to a disrup- 
tion, more or less complete, of the tendons of the biceps and brachialis 
anticus, together with the ligaments which surround the joint. 

(Sinfte writing the above my attention has been called to a review by 
Zeis of a paper on fractures of this apophysis, published by Lotzbeck, 
of Munich, in 1865. x The original paper furnishes five cases, to which 
the reviewer has added four more, one of which, Pennock's case, I have 
already spoken of. After a careful reading of the review, I fail to 
find conclusive evidence that the coronoid process was broken in either 
case. The evidence may be, indeed, in some of the cases probable, 
but never conclusive, since other explanations of the phenomena pre- 
sented than those which are here offered, would prove to me equally satis- 
factory.) 

Causes. — It is probable that this process will be sometimes broken 
in a fall upon the palm of the hand ; the force of the blow being re- 
ceived directly upon the lower end of the radius, and, through its 
numerous muscles and ligamentous attachments, being indirectly con- 
veyed to the ulna, producing a violent concussion of the coronoid pro- 
cess against the trochlea of the humerus, and resulting finally in a frac- 
ture of this process and a dislocation of both bones of the forearm back- 
wards. The gentleman seen by Sir Astley had fallen upon his extended 
hand while in the act of running. Brassard's patient had fallen also 
upon his hand with his arm extended in front. Pennock's patient, an 
old man of sixty years, had fallen upon the palm of his hand, and 
Fahnestock's fell upon the " back of the palm." In no other case is 
the point upon which the blow was received particularly mentioned. 
In two of the examples mentioned by Malgaigne there was a luxation 
of the forearm backwards ; such was also the fact in the case seen by 
Fahnestock ; in Couper's case it was dislocated backwards and out- 
wards, and in Sir Astley's case I infer that there was only a subluxa- 
tion of the ulna backwards. 

We know of no other causes, therefore, than such as equally tend to 
produce dislocations at the elbow-joint, unless we except direct crush- 
ing blows, which of course may break the bones at any point upon 
which the force happens to be applied. 

1 Schmidt's Jahrbuch for 1866. vol. 



322 , FRACTURES OF THE ULNA. 

Symptoms. — Partial or complete displacement of the ulna, or of the 
radius and ulna backwards, accompanied with the usual signs of these 
luxations; to which may be possibly added crepitus; and it is fair to 
presume that in some examples the fragment carried forwards by being 
driven against the trochlea, may be felt displaced and movable in the 
bend of the elbow. Brassard affirms that it was so with the patient 
whom he saw. If only the summit is broken off, the brachialis anticus 
could have no influence upon it; but if it were broken fairly through 
the base, it might be displaced slightly in the direction of the action 
of this muscle. 

The symptoms, however, which have been regarded as most diag- 
nostic, are the disposition to re-luxation manifested in most of these 
examples when the extension has been discontinued; and especially the 
fact that the olecranon was particularly prominent when the arm was 
extended, but that it resumed its natural position when the arm was 
flexed to a right angle. But I am unable to understand how either of 
these circumstances can be better explained upon the supposition of a 
fracture of this apophysis, than without such a supposition. If the re- 
duction of both bones is once effected, even though the support of the 
coronoid process is completely lost, the head of the radius ought to 
prevent a re-luxation unless the arm is disturbed again; nor can I 
understand why, when the elbow is bent, the re-luxation is less likely 
to occur; since, although in this position the humerus bears less di- 
rectly upon the process, the difference in this respect must be very 
little, for in whatever position the arm is placed, so long as the radius 
retains its position the ulna cannot be drawn very forcibly against the 
humerus; while, on the other hand, by flexing the arm the power of 
the biceps and of such fibres of the brachialis as remain attached to the 
ulna, to aid in the maintenance of reduction, is completely lost ; and 
at the same moment the resistance, and consequent power of the triceps 
to produce the luxation, are greatly increased. 

In short, we must confess that we are here, also, notwithstanding 
the confidence with which writers have spoken of the signs of this acci- 
dent, very much in doubt; nor do we see how these doubts can be re- 
moved until we have in detail the symptoms of at least one example, 
the indubitable existence of which has been subsequently verified by 
dissection. 

Prognosis. — In the case of Cooper's patient, seen several months 
after the accident, the ulna projected backwards while the arm was ex- 
tended, but it was without much difficulty drawn forwards and bent, 
and then the deformity disappeared. He thought that during exten- 
sion the ulna slipped back behind the inner condyle of the humerus. 
Brassard's patient, seen after three months, retained the power of pro- 
nation and supination, with also extension, but flexion was completely 
impossible, the forearm being arrested in this direction by the small, 
slightly movable fragment of bone in front of the elbow-joint, and 
which was supposed to be the process itself. Pennock's old man, who 
had met with the accident in boyhood, had still the radius luxated 
forwards and outwards, and the olecranon more salient backwards than 
in the sound arm. Extension and flexion were nearly but not quite 



COEONOID PROCESS OF THE ULNA. 323 

complete. Fahnestock informs us that his patient "recovered com- 
pletely/' but whether without deformity or maiming we are not told. 
Couper says the bone was united in four weeks, and that only a slight 
deformity and a little stiffness remained. Physick's patient made a 
perfect recovery. 

Let us come again to the dissections. Rejecting the doubtful speci- 
men belonging to Dr. Gibson, we have an exact account of only two, 
and, indeed, Sir Astley Cooper alone has described the mode of union. 
Samuel Cooper says that in the case of the University College speci- 
men the radius is dislocated forwards and upwards, and the olecranon 
is displaced backwards, but he does not say whether the coronoid pro- 
cess has united, nor described its position ; but Sir Astley informs us 
that in the example seen and dissected by him the process was united 
by ligament, which was sufficiently long and flexible to allow the frag- 
ment to move upwards and downwards in the motions of flexion and 
extension. 

In the absence of any other testimony, we may be allowed to express 
an opinion that when the fracture has taken place across the summit or 
above the insertion of the brachialis anticus, nothing but a ligamentous 
union can be regarded as possible, since the fragment can only derive 
nourishment from a few untorn fibres of the capsule and perhaps of 
the internal lateral ligaments; and although it may not be displaced, 
it cannot have the advantage of impaction, upon which alone, I sus- 
pect, a fracture of the neck of the femur w r ithin the capsule must rely 
for a bony union, if it ever does so unite. If, however the fracture has 
taken place at the base, and fortunately it has not become much dis- 
placed by the force of the concussion against the humerus, it does not 
seem to me so impossible that under favorable circumstances a bony 
union might now and then occur. It will be remembered that a good 
portion of the attachment of the brachialis anticus is still below the 
fracture, and the remaining fibres are not therefore very likely to dis- 
place the fragment, especially when the arm is sufficiently flexed, so as 
to properly relax this muscle. 

It will be of small importance, however, whether the union is bony 
or ligamentous, provided only there is not great displacement. 

Treatment. — Whatever view we take of the pathology of this acci- 
dent, the rational mode of treatment would seem to consist in flexing 
the arm at a right angle, and retaining it a sufficient length of time in 
that position ; not forgetting, how r ever, the danger of anchylosis from 
long-continued confinement in one position. 

An angular splint may be useful in preventing motion at first, but 
I think it ought not to be continued beyond seven or ten days at the 
most. After this, a simple sling is all that can be necessary, since 
from this period some motion must be given to the joint if we would 
take the proper precautions to prevent stiffness. Sir Astley Cooper 
thought the limb ought to be kept immovable three weeks, and Vel- 
peau preferred four ; but I cannot agree with them, believing that the 
question of the future mobility of the elbow-joint is vastly more impor- 
tant than the question of a bony or ligamentous union between the 
fragments. Couper says that he adopted in the treatment of the case 



324 FRACTURES OF THE ULNA. 

reported by him, extreme flexion; but both Physick and Fahnestock 
placed the arm at right angles, and Sir Astley Cooper has recommended 
the same position. The latter position has always the advantage in 
case permanent anchylosis occurs, and the former cannot add much to 
the chance of complete replacement of the fragment. 

Bandages are only serviceable to retain the splint in place, and they 
may be thrown aside as soon as the splint is removed. 

I 3. Fractures of the Olecranon Process. 

Causes. — My records furnish me with accounts of only fifteen of these 
fractures, and, so far as I have been able to ascertain, all were occa- 
sioned by falls upon the elbow, or by blows inflicted directly upon the 
part. Malgaigne has, however, been able to collect accounts of six ex- 
amples of fracture of the olecranon, produced, as is affirmed, by the 
violent action of the triceps ; as in pushing with the arm slightly flexed, 
in throwing a ball, in plunging into the water with the arms extended, 
etc. ; but only four of these reported examples does he think are suffi- 
ciently authenticated to entitle them to be received as facts ; nor do I 
think it possible to affirm positively that in any instance, where the 
whole process is broken off, the triceps alone has occasioned the separa- 
tion. For example, Capiomont reports the case of a cavalier, who, 
being intoxicated, was thrown head foremost from his horse, and, strik- 
ing probably upon his head, was found to have broken the olecranon 
process. We do not, in this example, see evidence alone of a forcible 
contraction of the triceps, but also of violent pressure against the hand 
and in the direction of the axis of the forearm toward the elbow-joint, 
by which the olecranon process might have been so thrown forwards 
against the fossa of the humerus as to cause its separation. The same 
explanation might apply to several of the other examples. 

Point and Direction of Fracture; Displacement, etc. — The process may 
be broken at its summit, at its base, or intermediate between these two 
extremes, the last of which is the most common. 

It is probable that when the action of the triceps alone has produced 
the fracture, it will be found that only that portion which receives the 
insertion of the triceps has been broken off. Malgaigne, who has been 
able to find upon record only two cases of a fracture of the extreme 
end of the process, declares that they were both occasioned by muscular 
action. 

Fractures of the middle are generally transverse, or only slightly 
oblique, occurring in the line of the junction of the epiphysis with the 
diaphysis. 

Fractures through the base are generally quite oblique, the line of 
fracture extending from before downwards and backwards, so that not 
only the whole of the process, but a portion of the back of the shaft is 
carried away ; and this accident can scarcely happen, except by a blow 
received upon the lower end of the humerus, directly in front of the 
process j or, what would amount to the same thing, by a blow from be- 




FRACTURES OF THE OLECRANON PROCESS. 325 

hind, received upon the ulna just below the olecranon process, or by 
wrenching the forearm violently back, while the humerus is fixed. 

The only displacement to which 
the upper fragment seems to be FlG - 112 - 

liable, is in the direction of the 
triceps; and the degree of this dis- 
placement does not depend so much 
upon the point at which the fracture 
has taken place as upon the violence 
which has occasioned it, the extent 
of the disruption of the ligaments, 
aponeurosis of the triceps and of the 
capsule, and upon whether, since 
the accident, the arm has been flexed Fractures at the base. 

or kept extended. 

In four instances I have found distinct crepitus immediately after 
the fracture had occurred, produced by only moving the fragment 
laterally, showing plainly that little or no displacement had taken place. 
The following example will show also that this displacement does not 
always happen even after the lapse of several days, and where no sur- 
gical treatment has been adopted. 

Samuel Duckett, set. 14, fell upon the point of the elbow, and two 
days after was admitted to the Buffalo Hospital of the Sisters of 
Charity. The elbow was then much swollen, but no crepitus could be 
detected, and he could nearly straighten his arm by the action of the 
triceps. On the sixth day, the swelling having sufficiently subsided, 
a distinct crepitus was discovered when the olecranon process was 
seized between the fingers and moved laterally. We extended the arm 
immediately, and applied a long gutta-percha splint to the whole front 
of the arm and forearm, securing it in place with a roller. On the 
eleventh day, five days after the first dressing, the splint was taken off 
and its angle at the elbow-joint slightly changed ; and this was repeated 
every day until the twenty -second from the time of the accident. The 
splint was then finally removed, when the fragment was found to be 
united without any perceptible displacement, and the motions of the 
joint were unimpaired. 

It must not be inferred, however, that it is always prudent to leave 
this fracture thus unsupported, since it has occasionally happened that 
the displacement, which did not exist at first, has taken place to the 
extent of half an inch or more, after the lapse of several days. Mr. 
Earle mentions a case in which the separation did not take place until 
the sixth day, when it was occasioned by the patient's attempting to tie 
his neckcloth. 

Symptoms, — The usual signs of a fracture of the olecranon process 
are, when the fragments are not separated, crepitus, discovered especi- 
ally by seizing the process and moving it laterally ; or, when displace- 
ment has actually taken place, the crepitus may be discovered some- 
times by extending the forearm, and pressing the upper fragment 
downwards until it is made to touch the lower fragment ; the existence 



326 FRACTURES OF THE ULNA. 

of a palpable depression between the fragments, partial flexion of the 
forearm, and total inability, on the part of the patient, to straighten it 
completely, or even to flex the arm in some cases. If the fragments 
do not separate, gentle flexion and extension of the arm, while the 
finger rests upon the process, may enable us to detect the fracture. 

It will sometimes happen that, owing to the rapid occurrence of 
tumefaction, the evidences of a fracture will be quite equivocal ; but, 
in all cases where a severe injury has been inflicted upon the point 
of the elbow, it will be well to suspend judgment until, by repeated 
examinations, made on successive days, the question is determined. 
Meanwhile, the arm ought to be kept constantly in an extended posi- 
tion, as if a fracture was known to exist.. 

Prognosis. — In a large majority of cases this process becomes re- 
united to the shaft by ligament, which may vary in length from a line 
to an inch or more, and which itf more or less perfect in different cases. 
Sometimes it is composed of two separate bands, with an intermediate 
space, or the ligament may have several holes in it ; at other times it 
is composed in part of bone and in part of fibrous tissue ; but most 
frequently it is a single, firm, fibrous cord, whose breadth and thick- 
ness are less than that of the process to which it is attached. 

If the fragments are maintained in perfect apposition, a bony union 
may occur, yet it is not invariably found to have taken place, even 
under these circumstances. Malgaigne thinks, also, he has seen one 
case in which there was neither bone nor fibrous tissue deposited be- 
tween the fragments. This was an ancient fracture at the base of the 
olecranon; the superior fragment remained immovable during the 
flexion and extension of the arm, yet it could be moved easily from 
side to side. 

In my own cases I have five times found the fragments united 
without any appreciable separation, and have presumed that the union 
was bony. One of these examples I have already mentioned ; the 
second was in the person of a lady aged about forty years, who, having 
fallen down a flight of steps on the 8th of September, 1857, sent for 
me immediately. I found a large bloody tumor covering the elbow- 
joint, but there was no difficulty in detecting a fracture of the olecra- 
non process. It was easily moved from side to side, and this motion 
was accompanied with a distinct crepitus. During the first week the 
arm was only laid upon a pillow, but as it was found to become grad- 
ually more flexed, and the swelling having in a great measure subsided, 
the arm was nearly, but not quite, straightened, and a long gutta- 
percha splint applied to the palmar surface of the forearm and arm. 
The fragments united in about twenty or twenty-five days, and without 
separation, so far as could be discovered in a very careful examination. 

The third example to which I have referred, occurred in a boy 
fourteen years old, and was treated by Dr. Benjamin Smith, of Berk- 
shire, Massachusetts. Sixty-nine years after, he being then eighty- 
three years old, I found the olecranon process united apparently by 
bone, but to that day he had been unable to straighten the arm com- 
pletely, or to supine it freely. 



FRACTURES OF THE OLECRANON PROCESS. 



327 



Fig. 113. 




Union by ligament. 



In one instance I found the fragment, after the lapse of one year, 
united by a ligament, which seemed to be about 
one-quarter of an inch in length, and the arm ap- 
peared to be in all respects as perfect as the other. 
He could flex and extend it freely. 

In the two following examples, also, the bond of 
union was ligamentous: 

John Carbony, set. 18, having broken the olec- 
ranon, it was treated with a straight splint. Nine 
years after, I found the process united by a ligament 
half an inch in length, and he could nearly, but 
not entirely, straighten the arm. In all other re- 
spects the functions and motions of the arm were 
perfect. 

A lad, set. 15, was brought to me by Dr. Lau- 
derdale, a very excellent surgeon in the town of 
Geneseo, Livingston Co., N. Y., whose olecranon 
process had been broken by a fall six months before, 
and at the same time the head of the radius had 
been dislocated forwards. I found the radius in 
place, and the olecranon process united by a ligament about half an 
inch in length. He was not able to straighten the arm completely, 
the forearm remaining at an angle of 45° with the arm. 

Treatment. — It will surprise the student who is yet unacquainted 
with the literature of our science, to learn that in relation to the treat- 
ment of a fracture of the olecranon process, a wide difference of opinion 
has been entertained as to what ought to be the position of the arm 
and the forearm, in order to the accomplishment of the most favorable 
results ; and that, while some insist upon the straight position as essen- 
tial to success, others prefer a slightly flexed position, and still others 
have advocated the right-angled position. Thus Hippocrates, and 
nearly all of the earlier surgeons, down to a period so late as the latter 
part of the last century, directed that the arm should be placed in a 
position of semiflexion ; Boyer, Desault, and, after them, most of the 
French surgeons of our own day, prefer a position in which the fore- 
arm is very slightly bent upon the arm; while Sir Astley Cooper, and 
a large majority of the English and American surgeons, employ com- 
plete or extreme extension. 

The arguments presented by the advocates and antagonists of these 
various plans deserve a moment's consideration. 

In favor of the position of semiflexion, requiring no splints, and, in 
the opinion of some writers, not even a bandage, but only a sling to 
support the forearm, it is claimed that it leaves the patient at liberty 
at once to walk about and to move the elbow-joint freely, so soon at 
least as the subsidence of the swelling and pain will permit, and that in 
this way the danger of anchylosis is greatly diminished; that, more- 
over, if anchylosis should unfortunately occur, the limb is in a much 
better position for the proper performance of its most ordinary func- 
tions than if it were extended. Some have also added to this argu- 
ment a statement that a fibrous union, under any circumstances, is in- 



328 FRACTURES OF THE ULNA. 

evitable, and that it is a matter of little consequence whether the 
ligament thus formed is long or short, since in either condition it will 
be equally serviceable. 

In reply to these statements, it may be said briefly that they are 
nearly all based upon false premises, or that they have been proven in 
themselves to be essentially erroneous. 

Anchylosis is always a serious event, which by all possible means 
the surgeon will seek to prevent, but position has nothing to do with 
determining this result; when it does occur, it may usually be ascribed 
either to the severity and complications of the original injury, to the 
violence of the consequent inflammation, or to having neglected, at a 
proper period and with sufficient perseverance, to move the joint. 

That a fibrous union is inevitable under any circumstances, has been 
fully proven to be an error; and it has been equally proven that the 
functions of the arm are generally impaired in proportion to the length 
of the uniting medium. 

The only argument which remains, and which really possesses any 
weight, is, that, if permanent anchylosis does actually occur, the arm, 
when semiflexed, is in a better position for the performance of its or- 
dinary functions; and this, considered as an argument in favor of the 
universal or even general adoption of the flexed position, is successfully 
met by a statement of the infrequency of permanent anchylosis after a 
simple fracture, when the case has been properly treated, whether by 
the flexed or straight position; while, if the limb is flexed, a maiming, 
as a result of the great, length of the intermediate ligament, is almost 
inevitable. 

Yet if, in any case, from the great severity and complications of the 
injury, especially in certain examples of compound and comminuted 
fracture, it were to be reasonably anticipated that permanent bony 
anchylosis must result, or even where the probabilities were strongly 
that way, the surgeon might be justified in selecting for the limb, at 
once, the position of semiflexion; or he might leave the arm without 
a splint, and at liberty to draw up spontaneously and gradually to this 
position, as it is always very prone to do. 

In favor of moderate, but not complete extension, it is claimed that 
it is less fatiguing than the latter position, while it accomplishes a more 
exact apposition of the fragments, if they happen to be brought actually 
into contact. 

I am unable, however, to understand how the apposition can be ren- 
dered less exact by complete extension, unless by this is meant a degree 
of extension beyond that which is natural, and which, I am well aware, 
is permitted to the elbow-joint when this posterior brace is broken off. 
It would certainly derange the fragments to place the arm in this ex- 
treme condition of extension — that is, in a condition of extension ap- 
proaching dorsal flexion, which is beyond what is natural. Indeed, 
perhaps we may admit that, in order to perfect apposition, the exten- 
sion ought to be less by one or two degrees than wliat is natural, suffi- 
cient to compensate for the trifling amount of effusion which may be 
presumed to have occurred in the olecranon fossa, and which would 
prevent the process from sinking again fairly into its fossa. 



FRACTURES OF THE OLECRANON PROCESS. 329 

As to its being less fatiguing, it is well known to those accustomed 
to treat fractures of the thigh by permanent extension that the muscles 
rapidly acquire a tolerance, which soon dissipates all feeling of fatigue, 
and that, after a few hours, or days at most, the patients express them- 
selves as being more comfortable in this position than in the flexed. 

Finally, the advocates of complete, natural extension claim that in 
this position alone is the triceps most perfectly relaxed, and conse- 
quently the most important indication, namely, the descent of the olec- 
ranon, most fully accomplished. In this opinion we also concur; and 
regarding all other considerations, in the early days of the treatment, 
as secondary to this one, we unhesitatingly declare our preference for 
what has been called the " position of complete extension," as opposed 
to flexion, semiflexion, or extreme extension. 

It only remains for us to determine by what means the limb can be 
best maintained in the extended position, and the olecranon process 
most easily and effectually secured in place. 

For this purpose a variety of ingenious plans have been devised, 

Fig. 114. 




Sir Astley Cooper's method. 

such as the compress and "figure-of-8 " bandage of Duverney, without 
splints ; or a similar bandage employed by Desault, with the addition 
of a long splint in front ; the circular and transverse bandages of Sir 
Astley Cooper, with lateral tapes to draw them together, to which also 
a splint was added ; and many other modes not varying essentially 
from those already described, but nearly all of which are liable to one 
serious objection, namely, that if they are applied with sufficient firm- 
ness to hold upon the fragment, and Boyer says they "ought to be 
drawn very tight," they ligate the limb so completely as to interrupt 
its circulation, and expose the limb greatly to the hazards of swelling, 
ulceration, and even gangrene. How else is it possible to make the 
bandage effective upon a small fragment of bone, scarcely larger than 
the tendon which envelops its upper end, and with no salient points 
against which the compress or the roller can make advantageous pres- 
sure? If, then, these accidents — swelling, ulceration, and gangrene — 
are not of frequent occurrence, it is only because the bandage has not 
been generally applied " very tight," and while it has done no harm, 
it has as plainly done no good. 

The dangers to which I allude may be easily avoided, without relax- 
ing the security afforded by the compress and bandage, by a method 
which is very simple, and the value of which I have already suffi- 
ciently determined by my own practice. 

The surgeon will prepare, extemporaneously always, for no single 
pattern will fit two arms, a splint, from a long and sound wooden shin- 

22 



330 



FRACTURES OF THE ULNA. 



gle, or from any piece of thin, light board. This must be long enough 
to reach from near the wrist-joint to within three or four inches of the 
shoulder, and of a width equal to the widest part of the limb. Its 
width must be uniform throughout, except that, at a point correspond- 
ing to a point three inches, or thereabouts, below the top of the olec- 
ranon process, there shall be a notch on each side, or a slight narrow- 
ing of the splint. One surface of the splint is now to be thickly padded 

Fig. 115. 




The author's method. 



with hair or cotton-batting, so as to fit all of the inequalities of the 
arm, forearm, and elbow, and the whole covered neatly with a piece of 
cotton cloth, stitched together upon the back of the splint. Thus pre- 
pared, it is to be laid upon the palmar surface of the limb, and a roller 
is to be applied, commencing at the hand and covering the splint, by 
successive circular turns, until the notch is reached, from which point 
the roller is to pass upwards and backwards behind the olecranon pro- 
cess and down again to the same point on the opposite side of the 
splint ; after making a second oblique turn above the olecranon, to 
render it more secure, the roller may begin gradually to descend, each 
turn being less oblique, and passing through the same notch, until the 
whole of the back of the elbow-joint is covered. This completes the 
adjustment of the fragments, and it only remains to carry the roller 
again upwards, by circular turns, until the whole arm is covered as 
high as the top of the splint. 

The advantage of this mode of dressing must be apparent. It 
leaves, on each side of the splint, a space upon which neither the 
splint nor bandage can make pressure, and the circulation of the limb 
is, therefore, unembarrassed, while it is equally effective in retaining 
the olecranon in place, and much less liable to become disarranged. 

Before the bandage is applied about the elbow-joint, the olecranon 
must be drawn down, as well as it can be, by pressure with the fingers, 
and a compress of folded linen, wetted to prevent its sliding, must be 
placed partly above and partly upon the process ; at the same time, 
also, care must be taken that the skin is not folded in between the 
fragments. 

When the fragments are not much, or at all separated, and consequently 
no such force is required to draw down the upper fragment, a splint 
may be employed, constructed like that recommended by Sir Astley 
Cooper, made of light wood, curved to fit the limb, or of gutta-percha, 
felt, or sole-leather. This should be covered with a flannel or cotton 



FRACTURES OF THE OLECRANON PROCESS. 331 

sack, and then secured in place by a roller. The sack will enable the 
surgeon to stitch the roller to the splint, and he can thus employ effect- 
ively the oblique and figure-of-8 turns about the elbow-joint. The im- 
movable dressings are, in these cases, cumbrous, liable to become loose, 
and they increase the danger of anchylosis. 

The dressing ought, no doubt, to be applied immediately, since, if 
we wait, as Boyer seems to advise, until the swelling has subsided, it 
will be found much more difficult to straighten the arm completely 
than it would have been at first, and the olecranon process will be more 
drawn up and fixed in its abnormal position. Something will be 
gained by these means, adopted early, even if the bandage cannot be 
applied tightly ; and moderate bandaging will not in any way interfere 
with the proper and successful treatment of the inflammation. We 
must always keep in mind, however, the fact that the fracture being 
usually the result of a direct blow, considerable inflammation and 
swelling around the joint are about to follow rapidly ; and on each suc- 
cessive day, or oftener if necessary, the bandages must be examined 
carefully, and promptly loosened whenever it seems to be necessary. 
For this purpose it is better not to unroll the bandages, but to cut 
them with a pair of scissors, along the face of the splint, cutting only 
a small portion at a time, and as they draw back, stitch them together 
again lightly; and thus proceed until the whole has been rendered 
sufficiently loose. 

As soon as the inflammation has subsided, and as early sometimes 
as the fifth or seventh day, the dressings ought to be removed com- 
pletely ; and while the fingers of the surgeon sustain the process, the 
elbow ought to be gently and slightly flexed and extended two or three 
times. From this time forward, until the union is consummated, this 
practice should be continued daily, only increasing the flexion each 
time, as the inflammation and pain may permit. If it is thought best, 
at length, to change the angle of the arm, and to flex it more and more, 
it may be done easily by substituting a very thick sheet of gutta-percha 
for either of the other forms of dressing. 

Dieffenbach has several times, in old fractures of both the olecranon 
and patella, where the fragments were dragged far apart, divided the 
tendons, so as to be able to bring the two portions together, and, by 
friction of them one upon the other, has endeavored to excite such 
action as might end in the formation of a shorter and a firmer bond of 
union. In some instances, it is said, considerable benefit was obtained, 
after all other means had failed ; in others, the result was negative. 
One example of an old ununited fracture of the olecranon is mentioned, 
in which he divided the tendon of the triceps, secured the upper frag- 
ment in place, and every fourteen days rubbed it well against the lower 
one; in three months "the union was firm." 1 

The practice, not without its hazards, needs further observations to 
determine its value. 

Recently a gentleman called upon me with his son, aged seven years, 

1 Dieffenbach, American Journal of Medical Science, vol. xxix, p. 478; from 
Casper's Wochenschrift, Oct. 2, 1841. 



332 FRACTURES OF THE RADIUS AND ULNA. 

who had an unreduced dislocation of the radius and ulna backwards 
of nine weeks' standing. While reducing this dislocation, it being 
necessary to flex the arm forcibly, the epiphysis constituting the olec- 
ranon process gave way, and became separated from one-half to three- 
quarters of an inch. This is the only example of separation of this 
epiphysis which has come to my knowledge. I have, however, twice 
since broken the olecranon in attempts to reduce old dislocations of the 
radius and ulna backwards, and I have not regretted the occurrence, 
since it enabled me to reduce the dislocations without cutting the triceps. 



CHAPTER XXIII. 

FRACTURES OF THE RADIUS AND ULNA. 

Causes. — In a large majority of the examples of this fracture seen 
by me, which have been of such a character as to warrant an attempt 
to save the limb, the accident has been occasioned by a fall upon the 
palm of the hand w T hile the arm was extended in front of the body. 
Yet this cause is not so constant as in fractures of the radius alone, 
since a considerable number have been occasioned by direct blows; 
and if we were to add to this estimate all of those bad compound frac- 
tures which have demanded immediate amputation, the proportion of 
fractures occasioned by direct and indirect blows might be found to be 
pretty nearly balanced. 

Point of Fracture, Character, Direction of Displacement, etc. — In a 
record of sixty-three fractures of both bones, not including gunshot 

Fig. 116. 




Fracture in the middle third. 



fractures, or those demanding immediate amputation, I have found six 
broken in the upper third, twenty-five in the middle third, and thirty- 
two in the lower third. 

In one case the radius was broken three-quarters of an inch above 
its lower end, and the ulna about one inch below the coronoid process. 
Four of the fractures belonging to the lower third were probably epi- 
physeal separations. 

Forty-nine were simple, eight compound, one was comminuted, three 
both compound and comminuted, one complicated with a fracture of 
the humerus, and one with a partial luxation of the lower end of the 



FRACTURES OF THE RADIUS AND ULNA. 



333 



radius. With three exceptions, all of these more serious accidents 
were arranged among fractures of the lower third, and generally the 
bones had been broken near the wrist. 

Partial fractures have been frequently observed, but having treated 
of these accidents fully in the general chapter on Incomplete Fractures, 
I shall not think it necessary to make any further allusion to them in 
this place. 

Prognosis. — Generally these bones unite in from twenty to thirty 
days; but I have seen the union occasionally delayed considerably 
beyond this time, and this delay has occurred especially in the case of 
the radius. Thus, in three cases of compound and comminuted frac- 
ture, the ulna united within four or five weeks, while the radius did 
not unite until the ninth or tenth week. Twice in simple fractures 
the ulna has united in the usual time, but the radius not until the 
sixteenth week. Once the ulna has united promptly and the radius 
remained ununited at the end of two years, at which time I practiced 
resection of the broken ends of the radius, and union was speedily 
established. 

On the other hand, I have once seen the union delayed four months 
in the case of the ulna, when the radius had united in the usual time ; 
and in one example of com- 



Fig. 117. 



Fig. Ill 



;/■; 



pound fracture both bones re- 
fused to unite until after the 
fifth month. 

Thirty-three of the whole 
number have united without 
any appreciable deformity, and 
fifteen are known to have left 
some marked defect, while two 
have resulted finally in the loss 
of the arm. Of the remainder 
I cannot speak positively. 

I have seen the fragments 
deviate slightly in almost every 
direction, but most often it has 
been noticed that the deviation 
was to the radial or ulnar sides. 
Thus, in three examples, two 
of which had been compound 
fractures, the bones have united 
in such a position as that from 
the point of fracture down- 
wards the forearm has been 
deflected to the ulnar side, and 
a marked projection has been 

left at the seat of fracture on the radial side ; while in two examples, 
both of which were simple fractures, exactly the opposite condition has 
obtained, the lower part of the forearm being deflected to the radial 
side. 

In a majority of cases the hand has been left with some tendency to 



Fracture in the 
lower third. 



Union with slight 
lateral displacement. 



334 FRACTURES OF THE RADIUS AND ULNA. 

pronation j in many instances this tendency was very slight and scarcely 
appreciable, but in others it has been quite marked, so that the patients 
have been wholly unable to supine the forearm except by a motion of 
the humerus in its socket. 

From what has been said, it must be seen that the prognosis in these 
accidents takes the widest range ; for while a larger proportion than in 
the case of almost any other of the long bones, unite without any 
appreciable deformity, a considerable number delay to unite, or do not 
unite at all, and some, even where the fracture is most simple, result 
in the complete loss of the limb. I am not now speaking of those 
more severe accidents in which the limb is at once condemned to am- 
putation, and which, in the case of the arm, are numerous; but, as 
I have already mentioned, our observations here apply only to cases 
which came under treatment with a view especially to the fracture. 

I shall state the facts more fully, and then perhaps we shall think 
it proper to inquire why, when, as a rule, the treatment is found to be 
so simple and successful, occasionally, and pretty often indeed, it re- 
sults so disastrously. 

A boy, aged about ten years, fell from a tree, April 22, 1856, frac- 
turing the right forearm near the low r er end of the middle third. It 
was evident that he had fallen upon the palm of his hand, as the lower 
fragments were inclined backwards, and one of the bones had been 
thrust through the skin on the front of the arm. 

It was at first dressed carefully by Dr. Wilcox, but the father of the 
lad, on the following day, placed him under the care of an empiric. 

Six days after the fracture occurred I was called to see him, with 
several other gentlemen. He was then suffering under a severe attack 
of tetanus which had commenced the night before. His arm was much 
swollen and very painful. He died the same evening. 

I was unable to learn very particularly what had been the treat- 
ment since the patient was seen by Dr. Wilcox, except that the band- 
ages had been most of the time very tight, and that the empiric had 
applied stimulating liniments, the boy constantly complaining greatly 
of the pain. I found the arm done up in a most slovenly manner with 
several narrow splints, underlaid with loose and knotty fragments of 
cotton-batting. 

We removed all of these immediately, and laid the arm upon a 
cushion supported by a board, to both of which the arm was lightly 
secured by a few turns of a bandage; cool water lotions were diligently 
applied, and chloroform administered by inhalation ; but the fatal event 
was delayed only a few hours. 

I shall not stop to inquire the cause of a result so unfortunate, where 
the treatment has been so palpably unskilful. 

I have already mentioned one case of gangrene of the hand, after 
a fracture of the lower part of the humerus. Norris, in a note to the 
American edition of Liston's Surgery, mentions a case which came 
under his observation in the Pennsylvania Hospital, the fracture hav- 
ing taken place just above the condyles; and still another has been 
related to me lately. I have brought together also no less than six 
cases of sloughing of the arm, after fracture of the radius, and one of 



FRACTURES OF THE RADIUS AND ULNA. 335 

sloughing from tight bandaging, where the radius was supposed to be 
broken, although the dissection proves that it was not. 

Robert Smith says that similar cases have been recorded in the Ga- 
zette Medicale. To these I shall now add eight examples of sloughing 
after fracture of both radius and ulna; making a total of eighteen cases 
in the upper extremities, in addition to those reported in the Gazette 
Medicate, an exact account of which I have not seen. 

John McGrath, set. 9, fell, July 2, 1847, from a ladder, about thirty 
feet to the ground, breaking the right radius and ulna in their middle 
thirds. A surgeon was in attendance about four or five hours after 
the accident occurred. He then reduced the fractures and applied two 
broad splints, one on the palmar and one on the dorsal surface of the 
forearm. Whether a roller was first applied to the arm or not, I am 
unable to say. The splints were secured in place by a roller and the 
arm laid in a sling. 

The third day was our national holiday, and the patient was not 
visited. Nor was he seen on the fourth day, not being found at home. 
On the fifth day the surgeon removed the bandages and found the arm 
gangrenous ; and within an hour afterwards I was requested to see it 
also. 

I found him lying in a miserable apartment, with his right arm 
resting upon a pillow. The arm, forearm, and hand were gangrenous 
through their whole extent ; and the skin of the right side, on the 
front of the chest, had assumed a dusky color, the extreme margin of 
which was indicated by an abrupt crescentic line. The thumb and 
fingers were black. His countenance was bright and cheerful, and his 
mind intelligent; pulse 75, and soft; tongue clean. He had slept un- 
disturbed the night before, and he had all along felt perfectly well, 
except that he had a slight diarrhoea. I was assured by the surgeon, 
and by all of the family, that the bandages had not been applied 
tightly; but we were told that on the third day of the accident, having 
been locked into the house by his mother, who was a peddler, he 
climbed out of the window, and that during all of that and most of 
the following day he was running about the streets firing crackers, 
during most of which time his arm was removed from his sling and 
hanging by his side. On the morning of the fourth day his mother 
noticed that his fingers were black, but she thought they were stained 
with powder. 

We ordered him to take one-quarter of a grain of opium every four 
hours, and applied a yeast poultice to the arm. On the seventh day 
the gangrene was still extending, and the pulse was 124; yet he con- 
tinued to feel well and to eat as usual. On the tenth day the line of 
demarcation had commenced opposite the shoulder-joint; and the cres- 
centic discoloration on the breast, which had at first spread rapidly 
until it covered nearly the whole upper half of the chest, was quite 
faint, in some parts almost lost. 

In a few days more he was removed to the county almshouse, the 
separation continuing rapidly to take place until the arm fell off at the 
shoulder-joint; after which he made a good recovery. 

A child, two years and three months old, had fallen from a chair 



336 FRACTURES OF THE RADIUS AND ULNA. 

upon the floor, a distance of about two feet. A German physician 
being called, found, as he believes, a fracture of both bones of the left 
arm. The fracture was near the middle. He immediately applied a 
roller from the fingers to the elbow, and over this three narrow splints 
made of the wood of a cigar-box. One of these was laid upon the 
palmar, one upon the dorsal, and one upon the radial side of the fore- 
arm, and the whole were bound together by another roller. From 
this time until the tenth clay the child continued to play about on the 
floor. Ten days after the accident occurred the doctor noticed that 
the ulnar side of the little finger was blue. The bandages were im- 
mediately removed, and were never again applied tightly. 

Three or four days after, I was requested to see the arm with the 
attending physician. The gangrene had continued to extend, involv- 
ing now the whole of the little finger and most of the thumb. There 
were also gangrenous spots over the hand and forearm, extending to 
w r ithin one inch from the elbow-joint ; these spots were more numerous 
in front and on the back of the forearm, and seemed to correspond to 
the pressure of the splints. The hand was much swollen, and also the 
arm above the line of the gangrene. The sloughs had already com- 
menced to be thrown off, and the gangrene was only extending in a 
few points. The child appeared well and rather playful, except when 
the arm was being dressed. I ordered a yeast poultice, and a nourish- 
ing diet. 

I have since learned that the arm and a large portion of the hand 
were finally saved. 

About the year 1865, as near as I can remember, a lad aged about 
nine years was brought to the Long Island College Hospital Dispen- 
sary, with a fracture of the radius and ulna. It was dressed by the 
visiting surgeon with splints and bandages. He did not return to the 
Dispensary as directed to do, and on the third or fourth day portions 
of the arm and hand were found in a gangrenous condition. 

In March, 1867, I was consulted by the parents of D. C, of Catta- 
raugus Co., N. Y., on account of a serious distortion of the hand and 
forearm, caused by sloughing, splints and bandages having been ap- 
plied by her surgeon for a supposed fracture ; but when examined by 
me about ten weeks after the accident, there was no evidence that the 
bones had ever been broken. She complained to her surgeon that the 
bandages were too tight, but he thought otherwise, and they were not 
removed until the third day, when the gangrene had already occurred. 
The child was five years old at the time of the accident. 

A young man, set. 20, suffered a simple fracture of the right radius 
and ulna March 14, 1874. On the same day it was dressed with a 
roller next to the skin and over this the splints. On the following 
day the fingers were black, but the same dressings were continued, 
and they were not removed completely until the next day. He was 
admitted to Bellevue on the 16th, and by courtesy of Dr. Gouley I 
was permitted to examine the arm on the 7th of April. He had then 
lost all of his fingers, except a portion of the thumb, and there was 
extensive sloughing and suppuration along the forearm. His condition 
was very critical. His death took place a few days later. It is worthy 



FRACTURES OF THE RADIUS AND ULNA. 337 

of remark that, after the first few hours, there was no pain in the arm 
although the dressings had not been removed. 1 

Alice Thompson, set. 50, fell upon her left hand in March, 1870, 
causing a compound fracture of the radius and ulna, about three inches 
above the wrist-joint. She went at once to one of the New York City 
Dispensaries, and the surgeon dressed the arm with splints, applying 
the bandages " snugly." Two days later she was brought to one of 
my wards at Bellevue, with the back of the hand and most of the fore- 
arm in a state of gangrene, evidently caused by the bandages. Seven 
or eight days later she died before the house surgeon could reach her, 
from a secondary haemorrhage. 

In the following case there was probably no fracture; no doubt 
could be entertained, therefore, as to the cause of the gangrene. 

A girl, set. 5, fell upon the palm of her hand in 1866. A surgeon 
saw her within one hour, put on two wooden splints, with cotton 
batting laid loosely underneath, securing them with a roller. Half an 
hour after it was dressed the fingers were blue, and the pain was so 
great that the surgeon was recalled. On his arrival he said it was not 
too tight. On the following day the condition was the same, but the 
surgeon refused to loosen the dressings. Two days later he removed 
the bandage, and found a slough extending nearly the whole length of 
the palmar surface of the forearm. Some months later I found the arm 
straight, but the hand much distorted by the cicatrix. 

I have now to relate a case in which sloughing and death occurred 
as the consequence of a tight bandage, the patient being under my 
own charge. 

James Brachen, set. 22, was admitted to ward 12, Bellevue Hos- 
pital, April 1, 1871, with a fracture of the left forearm, near its 
middle, caused by the kick of a horse on the day before. On the 
same day I dressed the fracture before the class of medical students in 
the hospital, using a palmar and dorsal board splint, covered and 
stuffed with cotton batting, according to my usual method ; securing 
the splints with a roller, including the hand and forearm. The arm 
was then placed in a sling and he was sent to his ward. The following 
day being Sunday I did not visit the hospital. On Monday I inquired 
for him, and learned that he was out walking in the yard. Tuesday I 
met him, returning from a walk in the yard, just as I was leaving the 
ward. He was apparently in perfect health, but as I stopped him a 
moment to look at his arm I saw that the hand was swollen and 
purple. The dressings were immediately removed, and the patient 
placed in bed. There were upon the arm two spots looking like 
superficial sloughs. He was suffering no pain. The gangrene subse- 
quently extended until it involved a large portion of the hand and 
forearm, and on the eighteenth day after the receipt of the injury he 
died. 

I will submit the case without comment, except to say that a careful 
and daily observation of the condition of the hand, and a prompt 
removal or loosening of the dressings when the hand first showed 



1 New York Jour. Med., June, 1874. 



338 FRACTURES OF THE RADIUS AND ULNA. 

symptoms of arrest of circulation, would probably have prevented 
this disastrous result. The splints and bandages were removed the 
first time I saw him after the original dressings had been made, but 
this was too late ; some one should have seen the approaching cloud 
before it was ready to burst. 

South also says that he has seen one or two instances of mortifica- 
tion produced by splints applied too tightly, and previous to the acces- 
sion of the swelling after fracture, and which had not been loosened as 
the swelling increased. 1 

How shall we explain the frequency of these accidents after fracture, 
especially of the forearm ? 

Malgaigne, speaking of factures of both bones of the forearm, re- 
marks that " when the displacement is considerable, or more especially 
when the outward violence has been excessive, we frequently see follow 
a very intense inflammatory swelling, and there is no fracture which 
complicates itself so easily with gangrene under the pressure of appa- 
ratus.- n 

Says Nelaton : " If we make choice of the apparatus of J. L. Petit, 
it is necessary that it shall not be applied too tightly, for, as Professor 
Roux has long since remarked, fractures of the forearm are those 
which furnish most of the examples of gangrene in consequence of an 
arrest of the circulation. This is easily understood, if we consider on 
the one hand the superficial position of the two principal arteries of 
the forearm, and on the other the disposition of the apparel, which 
must almost infallibly compress the arteries to a great extent." 3 

I do not think that this accident is due always to the negligence of 
the surgeon. It may be due many times to the carelessness of the 
parents or of the patient himself; as in the case of the boy who came 
under my own observation, and who lost his arm at the shoulder-joint. 
Sometimes also it may be due rather to the severity of the original 
injury, which, the experience of every surgeon will prove, is occasion- 
ally competent to the production of such bad results. A number of 
unfortunate circumstances may have concurred, such as a severe injury, 
especially where the skin has remained unbroken and the effused 
blood has had no opportunity to escape — the broken bone may have 
rested against *the trunk of a main artery, causing an arrest of its circu- 
lation — the constitution may be impaired by previous illness, or it may 
be suffering under the shock of the injury ; yet that it may be and too 
often is the result of maltreatment, on the part of the surgeon, is un- 
deniable. It is proper, however, to discriminate between the respon- 
sibility which attaches to the surgeon as the true exponent of the state 
of his art, and that which attaches to the art itself as taught by the 
masters. 

The old surgeons applied first a roller to the hand and forearm, and 
•over this their various splints. J. L. Petit thought he had made a 
valuable improvement upon this simple plan in laying over the roller 
a compress, supported by a splint, designed to press between the bones, 

1 South, note to Chelius's Surg., vol. i, p. 69. 

2 Malgaigne, Frac. et Disloc , torn, i, p. 589. 

3 Nelaton, Pathologic Chirurgicale, p. 735. 



FRACTURES OF THE RADIUS AND ULNA. 339 

and to antagonize thus the action of the roller in drawing the frag- 
ments toward each other. Duverney believed that this object would 
be best accomplished by placing the pad against the skin, and under a 
circular compress; while Desault declares all of these modes inefficient, 
and announces a method which he regards as accomplishing at once 
and completely all of the indications ; the sole peculiarity of which 
method consists in placing the graduated pads against the skin, and 
securing them in place by a roller. Boyer adopts the same method 
without any modifications, and Mr. Hind, in his illustrations of frac- 
tures already referred to, has seen fit to recommend the same, at least 
in fractures of the radius. 

It is quite obvious that between these various methods there remains 
very little if anything to choose, the differences being too trifling and 
unessential to claim serious consideration. Each alike is inadequate 
to accomplish any amount of useful pressure between the fragments ; 
each alike is calculated to bind the bones one against the other, and 
each alike exposes to the danger of ligation and of gangrene. 

Says M. Dupuytren : " The practice of rolling the arm before the 
splints are applied, whether internal or external to the pads and com- 
presses, is eminently mischievous; and instead of fulfilling, directly 
counteracts, the indications which it is most important to keep in view 
in the treatment of fractures of the forearm." 

And notwithstanding the same sentiment has been reiterated by Vel- 
peau, Malgaigne, Nelaton, Samuel Cooper, Bransby Cooper, Erichsen, 
Amesbury, Gibson, and others, yet we find to-day the great surgeon of 
Heidelberg, Chelius, recommending the roller to be applied under the 
splints, after the manner of Desault; while Listen, Syme, and Fergus- 
son, who perhaps represent the Edinburgh school, use only pasteboard 
splints above the compresses, over which is immediately applied the 
roller ; a practice which differs very little from that recommended by 
Desault, and is equally obnoxious to criticism. 

Among the American surgeons, I believe, the advice and practice of 
Dupuytren have received almost universal assent, only that we have 
always employed splints much wider than those recommended by this 
distinguished surgeon. I cannot therefore agree with my accomplished 
countryman, Dr. Reynell Coates, if in the following paragraph he 
means to imply that American surgeons generally adopt Desauit's treat- 
ment. Such at least is not my experience. " It would be wrong," 
says Dr. Coates, " not to bear testimony, on every possible occasion, 
against the folly so universally prevalent, that induces surgeons to 
apply a bandage directly to the forearm before applying splints in in- 
juries of this character. We have often asked for a rational explana- 
tion of this practice, without effect. It is directly at war with the ac- 
knowledged indications in the coaptation of the fragments, and when 
the object of the whole apparatus is to thrust asunder their extremities, 
it commences by binding them together. Few plans in surgery are 
more generally followed; none can be more absurd." 

Of the estimate placed upon the roller by M. Mayor, the reader will 
judge by a reference to the passage which I shall quote further on, when 
I shall speak of the value of the interosseous compresses. 



340 FRACTURES OF THE RADIUS AND ULNA. 

Amesbury and Bransby Cooper use no rollers at all — not even to 
secure the splints in place, they being made fast to the forearm by straps 
or tapes. 

Mr. Amesbury and Mr. South also endeavor to give to their splints 
an appropriate shape, by having them constructed with more or less 
convexity. It must be noticed, however, that the practice of these two 
gentlemen is very dissimilar, for while Mr. South applies the convex 
surface of his splint to the interosseous space, Mr. Amesbury reverses 
this plan, and applies the concave surface directly to the skin. 

As to the width of the splints, surgeons are also very generally 
agreed, at the present day, that they ought to be wider than the arm, 
so as to prevent the roller or the tapes from resting against its sides. 

I do not intend to deny peremptorily, and without qualification, the 
value of the graduated compresses, which, as we have seen, are usually 
laid along the interosseous space to press the fragments asunder. It is 
necessary, however, to caution the surgeon against their injudicious use. 
M. Nelaton has well remarked of the apparel employed by J. L. Petit, 
that it must inevitably compress, to a great extent, the arteries of the 
forearm; and the remark is applicable, in only a less degree, to all of 
those other plans in which the compress is employed. And I suspect 
that to this portion of the dressing, quite as much as to any other cause, 
are due those frightful accidents of which we have already spoken. 
The arteries are not only exposed, from their superficial position, to 
pressure from a compress, but, in addition to this, it will be noticed 
that the two principal arteries, the radial and the ulnar, are situated 
upon a broad and flat surface of bone, along which this pressure must 
operate most advantageously. So early as the year 1833, M. Lenoir, 
in his inaugural thesis at Paris, called attention to this danger, and 
from time to time surgeons have continued to advert to it, but they 
have seldom given to its consideration that prominence which its im- 
portance deserves. 

I have observed another fact in this connection : when this compress 
is extended low down on the palmar surface, within an inch or two of 
the wrist-joint, it soon becomes excessively painful, and sometimes even 
wholly insupportable, in consequence of the pressure made upon the 
median nerve ; and I find myself always obliged to exercise great care 
in the adaptation of the pads at this point. For this reason alone, I 
believe, in case of a fracture near the base of the radius, the lower frag- 
ment, if it were thrown toward the ulna, could not be retained in its 
place by graduated compresses. 

In short, finding that broad splints, properly covered and padded, 
answer very well to crowd the muscles into the interosseous space, so 
far as it is proper to do so, and believing that this mode is less painful 
and less dangerous, I seldom resort to graduated compresses, nor can I 
appreciate their necessity, or indeed their utility. Mr. Lonsdale also 
concurs with me in attaching very little value to this part of the ac- 
customed apparel. 

But listen to the surgeon of Lausanne, M. Mayor : " What signify 
graduated compresses placed between the bones of the forearm for the 
purpose of separating them from each other ? These bones will not 



FRACTURES OF THE RADIUS AND ULNA. 341 

have that constant tendency to approach each other which has been 
supposed, provided, first, that they have been well reduced; second, 
that for the purpose of maintaining them in position we do not make 
use of a preliminary circular bandage, whose action is an absurdity; 
and, in short, provided we make the retentive means act chiefly upon 
the palmar and dorsal surfaces of the forearm." 1 

M. Mayor proceeds to declare these convictions to be the result of 
his own experience, both in the treatment of simple and compound 
fractures of the forearm, and he intimates that in the use of the cir- 
cular bandage with compresses, surgeons seem to have rolled the arm 
into a cylinder and drawn the bones together, in order that they might 
tax their ingenuity to discover some means to again separate them. 

Surgeons have generally, after the splints have been applied, placed 
the forearm in a position of semi-pronation, or midway between supi- 
nation and pronation, so that the radius should be uppermost; it being 
assumed that in this position the two bones are most nearly parallel, 
and least inclined to displacement. Such, indeed, was the practice of 
Hippocrates, Paulus .ZEgineta, Celsus, Albucasis, and of most surgeons 
down to this day ; but Lonsdale, Robert Smith, Nelaton, and South 
have lately called in question the correctness of this mode of dressing, 
at least when it is adopted as a universal rule. 

I have before mentioned, when treating of fractures of the ulna, 
that M. Fleury had, in one instance, been unable to bring the frag- 
ments into apposition except by forced supination of the forearm ; and 
in certain fractures we have seen the same position recommended by 
Lonsdale. 

Says Mr. South, in a note to Chelius : " In fractures of both bones 
the forearm is best laid supine ;" and Nelaton declares that in fractures 
of the radius and ulna at any point of their upper thirds it will be 
necessary to supine the arm, both in the reduction and during the sub- 
sequent treatment ; but that in fractures of the inferior two-thirds we 
may place the limb in a condition of semi-pronation. 

It seems very probable, however, that both of these gentlemen have 
received their suggestions from Mr. Lonsdale, who, as we have already 
seen, has treated the question very much at length, and who has finally 
declared his decided preference for the supine position in the treatment 
of all fractures of the forearm. His arguments are certainly very in- 
genious, and as applied to fractures of the radius above the insertion of 
the pronator radii teres, they seem altogether conclusive; and, indeed, 
they commend themselves very strongly to our judgment, as applied 
to all fractures of the forearm. They are sustained also by the results 
of his own experience, and I see no good reason why they should not 
be more thoroughly examined and tested by other surgeons. The ad- 
vantages which he claims for this method are, more perfect coaptation 
of the broken ends, less liability of the fragments to encroach upon 
the interosseous space, and consequently less danger of anchylosis be- 
tween the bones and of non-union of the fragments, more complete 

1 Bandages et Appareils a Pansements, ou Nouveau Systeme de Deligation Chi- 
rurgicale, par M. Mathias Mayor, Chirurg. en Chef de l'Hopital de Lausanne, 
Switzerland. Paris ed., 1838, p*. 345. 



342 FRACTURES OF THE RADIUS AND ULNA. 

restoration of the power of supination, and less tendency to lateral dis- 
tortion, or of falling off to the ulnar or radial sides. 

My own cases, treated by the usual method, have shown that while 
supination is frequently impaired, and sometimes entirely lost, prona- 
tion is rarely affected; and that lateral displacements are much more 
common than displacements forwards or backwards. How this posi- 
tion, semi-pronation, may tend to the production of a permanent pro- 
nation, I have fully explained when speaking of fractures of the head 
of the radius; and the influence of the same position, the forearm 
resting upon its ulnar margin in the sling, in the production of a 
lateral deviation, is also easily understood. If the arm rests upon the 
sling so that its weight bears more upon the point of fracture than 
upon the extremities of the bones, then the ulna, or both ulna and 
radius, will incline gradually to the radial side, and the hand will fall 
off to the ulnar side ; or if the sling rests under the wrist or hand 
chiefly, the hand will ascend to the radial side, and the broken ends of 
the two bones will project to the ulnar side. 

If this plan is adopted, viz., laying the hand and forearm upon its 
back, instead of upon its ulnar margin, the elbow should remain at the 
side, the humerus falling perpendicularly from its socket ; and the 
forearm should rest in the sling directed forwards from the body. 

The following is the method usually employed by the author : 

Two thin, but firm, wooden splints are prepared, of uniform breadth, 
sufficiently wide that when the roller is applied it shall touch only 

lightly the radial and ulnar margins 
fig. ii». of the forearm. The palmar splint 

should be long enough to extend from 
the bend of the elbow, the arm being 
flexed, to the metacarpo-phalangeal 
Palmar splint. articulations, the fingers being flexed. 

The dorsal splint should be a little 
shorter, or of a length to extend from the base of the olecranon process 
to the carpus. Both of these splints must be covered with cloth, and 
properly padded with cotton batting; taking care to leave but little of 
the cotton placed where it might press upon the radial and ulnar arte- 
ries and median nerve ; that is, at the front of the Avrist. 

The splints being carefully fitted, are applied while the forearm is 
held at a right angle with the arm, and in a position midway between 
pronation and supination, one to the palmar and the other to the dorsal 
surface of the forearm, and secured with a roller. There must be no 
pressure against the humerus at the bend of the elbow; and the fingers 
must be flexed easily over the lower end of the palmar splint. The 
dorsal splint should not extend beyond the lower end of the radius 
and ulna. It is understood, of course, that while the splints are being 
secured in place, extension and counter-extension are maintained for 
the purpose of securing coaptation of the broken extremities as far as 
possible. The dressing being completed, the forearm is suspended in a 
sling. 

Finally, whatever may be the mode of dressing, let me repeat the 
injunction to examine the arm frequently. No surgeon can do justice 




FRACTURES OF THE CARPAL BONES. 343 

to himself, or to his patient, who does not look at the arm at least once 
in twenty-four hours during the first ten or fourteen days, and in some 
cases the patient ought to be seen twice daily. 

When the fracture is compound, it is often quite impossible to retain 
the forearm in the half-pronated position; since, when thus placed, and 
only slightly supported, as it must necessarily be, it inevitably falls 
over upon its palmar surface. 

There can be no doubt that in such a case we ought, from the first, 
if it is found practicable, to place it upon its back, in a position of com- 
plete or nearly complete supination. For this purpose, a single broad 
splint, carefully cushioned, and covered with oiled cloth, is the most 
suitable. Upon this the forearm is to be laid, and secured gently with 
a few turns of the roller. If the patient is able to do so, and wishes 
to walk about, the board may be suspended to the neck, as recommended 
by M. Mayor. 

I have said that we ought, in cases of compound fracture, to lay the 
forearm upon its back, if practicable. I am sure, however, that the 
surgeon will find very many patients who cannot endure this position, 
and he may be compelled, therefore, to lay the limb upon its palmar 
surface, or to leave it to assume any other position in which it may be 
the most at ease. In conclusion, I desire again to call attention to the 
splint employed by Dr. Scott, and of which an illustration is given in 
the chapter which treats of fractures of the radius. 



CHAPTEE XXIV. 

FKACTUKES OF THE CARPAL BONES. 

The few cases of fracture of the carpal bones, which have come under 
my observation were, without exception, compound and complicated, 
and have resulted in the complete loss of the hand, or in some less 
serious, but never inconsiderable, mutilation or maiming. 

In no case has a treatment been adopted which might be regarded as 
having reference to the fracture, or the purpose of which was to insure 
apposition and union of the fragments. 

It may be proper to assume in a matter so easily comprehended, what 
actual and recorded experience has not proven, namely, that simple 
fractures of these bones will demand very little surgical interference, 
and that they will unite generally without much displacement, and 
without any considerable maiming. It is, indeed, quite probable that 
some degree of anchylosis between their adjacent surfaces will occur, 
yet even in the normal condition they enjoy so little motion as to render 
it doubtful whether its complete loss would be very sensibly felt. 

In cases of comminuted, compound, and otherwise complicated frac- 
tures of the carpal bones, which accidents are sufficiently common, the 
surgeon has only, I conceive, to follow carefully those general or special 



344 FRACTURES OF THE METACARPAL BONES. 

indications which may happen to be present, the precise character of 
which it would be difficult to anticipate, and for the treatment of which 
it would be unsafe to attempt in a written treatise to provide. 



CHAPTEE XXV. 

FRACTURES OF THE METACARPAL BONES. 

Development of Metacarpal Bones. — These bones are each formed 
from two centres of ossification. In the case of the metacarpal bones 
of the four fingers there is one centre for each shaft, and one for each 
distal extremity ; but in the case of the metacarpal bone of the thumb 
there is one centre for the shaft and one for the proximal extremity. 
All these epiphyses unite with the shafts at about the twentieth year. 

Causes. — These bones, also, are generally broken by direct blows; 
and in that case the injury is often of such a character as to demand 
amputation, and does not therefore belong to that class of accidents of 
which it is the purpose of this volume to treat. Not an inconsiderable 
number, however, are the results of indirect blows, and especially of 
blows upon the knuckles received in pugilistic encounters. Thus, in a 
record of fifteen fractures, I find this cause assigned in six ; in one other 
instance it was occasioned by falling upon the clenched fist, and in one 
by striking a board ; so that the fracture has resulted from a blow upon 
the ends of the bones in eight of the fifteen examples. 

Point of Fracture; Direction of Displacement ; Symptoms. — Once the 
fracture has occurred in the metacarpal bone of the thumb; seven times 
in the metacarpal bone of the index finger ; once in the second finger ; 
three times in the ring finger, and three times in the metacarpal bone 
of the little finger. Two of those belonging to the ring finger, and the 
three occurring in the little finger, were produced by blows with the 
clenched fist, and in each instance the fracture was in the lower or distal 
third of the bone. Two of the fractures of the metacarpal bone of the 
index finger were produced also in the same way ; but the fractures 
were near the middle of the bone. Of the whole number, seven were 
broken through the lower third, five through the middle, and three 
through the upper third. 

In every instance where the bone is known to have been broken by 
a blow upon the knuckles,* the distal end of the distal fragment was 
thrown toward the palm, and this fragment was salient backwards at 
the point of fracture. 

In the following case the bone was probably separated at the 
epiphysis. 

Thomas Rose, set. 8, fell down a flight of steps, September 11, 1855, 
breaking the metacarpal bone of the index finger of the right hand 
near its lower extremity, and apparently at the junction of the epiphysis 
with the diaphysis. 



FEACTUEES OF THE METACARPAL BOXES. 345 

I saw the lad about sixteen hours after the accident. The lower frag- 
ment, projecting abruptly into the palm of the hand, could be easily re- 
placed, or with only moderate effort, yet immediately when the support 
was removed it would become displaced. There was no crepitus. 

It was dressed very carefully with a splint and compress; but not- 
withstanding our continued efforts to keep the fragments in place, the 
epiphysis united considerably depressed toward the palm. 

In one instance, also, I think the bone was rather bent, or partially 
fractured, than broken completely. This was the case of fracture of 
the metacarpal bone of the ring finger, produced in a gymnasium by 
striking with the clenched fist against a board, and to which I have 
already alluded. I did not see the young man until four weeks after 
the accident, when I found the lower end of the bone depressed toward 
the palm, and the angle made at the point of fracture was rather 
rounded and quite smooth; it was also, tender at this point, but the 
bone was firm and unyielding. Four years after I was permitted to 
examine it again, and I found the same slight deformity still continuing. 

A partial explanation of the fact that the distal end of the distal 
fragment is generally displaced toward the palm, may be found in the 
natural curve of these bones, which is such that when the fracture has 
been produced by a counter-stroke, the distal end would almost neces- 
sarily be driven in this direction ; and a farther explanation has been 
suggested by Mr. B. Cooper, namely, the action of the interossei. 

Results. — Generally, when the fracture is simple, and the displace- 
ment is not considerable, the nature of the accident is overlooked, and 
some deformity must inevitably ensue. In a majority of the cases 
which have come under my observation this has been the fact, and the 
bone has remained slightly bent at the seat of fracture, but without 
affecting in any degree the value of the hand. 

The following example has furnished the most serious result of any 
case of simple fracture of these bones which has come under my notice. 

Louis Mooney, set. 25, struck a man with his clenched fist, Xovem- 
ber 4, 1856, breaking the metacarpal bone of the index finger of the 
right hand near its middle. Great swelling and suppuration followed 
the injury. 

February 21, 1857, nearly four months after the injury was received, 
he consulted me. There existed at this time a complete anchylosis at 
the wrist-joint, and partial anchylosis in the fingers. The hand was 
deflected forcibly to the radial side. At the point of fracture the frag- 
ments were salient backwards and quite prominent, but firmly united. 

Even when the existence of the fracture is recognized, it is not always 
easy to retain the fragments in place, as the case of epiphyseal separa- 
tion alreadv mentioned, and the following case, will illustrate. 

Miss E.*, of Erie Co., N.Y., set. 18, fell, August 7, 1853, striking 
upon her right hand with her fiugers forcibly bent into the palm of the 
hand. On the following day she consulted me at my office, and I 
found the metacarpal bone of the ring finger broken about three-quar- 
ters of an inch from its distal end, and the distal extremity of the frag- 
ment depressed toward the palm. A feeble crepitus, with distinct mo- 
tion, completed the diagnosis. The young lady was very anxious to 



346 FRACTURES OF THE METACARPAL BONES. 

have a perfect hand, and I was determined if possible to accomplish it. 
Finding that the joint end of the distal fragment was constantly dis- 
posed to fall toward the palm, I constructed a gutta-percha splint for 
the hand and fingers, and after placing a pad directly underneath this 
fragment, I secured it firmly with a roller. From this time until the 
end of four weeks she remained under my care, visiting me as often as 
once or twice a week, and at each dressing I found the distal fragment 
slightly displaced in the same direction as at first, nor was I able ever 
to make it resume completely its position. 

Ordinarily, however, no such difficulty is experienced, and the bone, 
supported by such simple means as we shall presently direct, unites 
quickly and without deformity. 

An engineer was struck by a piece of iron in such a way as to break 
his right forearm and the second metacarpal bone of the same hand. 
The fracture of the metacarpal bone was compound and about three- 
quarters of an inch from its proximal extremity. When he called 
upon me, which was immediately after the injury was received, I found 
the proximal fragment projecting directly backwards, its sharp point 
rising above the skin, into which position it was evidently drawn by 
the action of the extensor carpi radialis longior muscle. By pressure 
alone it could be replaced, but it was much more easily reduced when 
the hand was forcibly carried backwards on the forearm. I therefore 
secured the hand in this position with appropriate splints, and it Avas 
maintained in this posture during most of the subsequent treatment. 
Union finally took place, but not without some backward displacement. 
Four months after the accident occurred, on the 31st of December, 
1858, 1 examined the hand, and found the skin healed over completely, 
the end of the fragment having become rounded and smooth, so as not 
to give him any degree of annoyance. His wrist was as flexible and 
as strong as before. No doubt the projection of the fragment might 
have been prevented entirely by cutting at the point of its attachment 
the tendon of the extensor muscle, but this would have sensibly weak- 
ened the wrist-joint, and I preferred the alternative of a projection of 
the fragment. 

Treatment — With moderate extension made upon the finger corre- 
sponding to the broken bone, while the fragments are forced home by 
firm pressure, the bone may generally be brought at once into line, 
and we may now proceed to adapt a gutta-percha, felt, or thick paste- 
board splint, to either the whole surface of the back or palm of the 
hand and fingers, while they are held in a position of easy flexion. It 
is not very material to which of these surfaces the splint is applied; or 
rather, I may say, it ought to be applied to the one or the other accord- 
ing as circumstances seem to indicate. It should be well padded, and 
especially at certain points, in order to the more effectual support of 
the fragments. It is then to be secured in place with several turns of 
a roller. When either of the metacarpal bones, except those of the 
great or ring finger, is broken, the splint must be wide enough to secure 
the sides of the hand against the pressure of the roller. 

Thus dressed, the hand may be laid in a sling beside the chest, or 
while sitting it may rest upon a table. 



FRACTURES OF THE FINGERS. 347 

The apparel must be examined daily, and readjusted as often as it 
shall become disarranged, or as a doubt shall ^arise as to the condition 
of the parts. 

When the fracture is followed by much inflammation, or occurs near, 
and especially if it actually involves a joint, the same precautions must 
be adopted to prevent anchylosis as in the case of similar fractures in 
other bones. 



CHAPTEE XXVI. 

FRACTURES OF THE FINGERS. 

Development of the Phalanges of the Hand. — The phalanges of the 
hand are formed from two centres of ossification, namely, one for each 
shaft and one for each proximal end. Ossification commences in the 
shafts at about the sixth week ; in the epiphyses of the first phalanges 
between the third and fourth years, and in the. epiphyses of the two 
last phalanges somewhat later. Complete bony runion takes place be- 
tween the epiphyses and the shafts at from the eighteenth to the twen- 
tieth year. 

Causes. — I do not remember to have seen a fracture of one of the 
phalanges produced by a counter-stroke ; I am aware, however, that 
they are occasionally produced in this way, as by falling upon the 
ends of the fingers, and especially by the stroke of a ball in the game 
of base. 

The fact, however, that they are generally the consequence of a direct 
blow, and that the finger bones are small and only protected by a thin 
covering of skin and tendons, renders them peculiarly liable to com- 
minution and to other serious complications. Thus, in a record of 
thirty fractures, only eighteen were sufficiently simple to warrant an 
attempt to save them , and only five are recorded as simple fractures 
without complications. 

Point of Fracture and Direction of Displacement. — In the following 
case there was probably an epiphyseal disjunction. A lad four years 
old was admitted to the Hospital of the Sisters of Charity, Dec. 24, 
1849, with a simple fracture of the first phalanx of the ring finger of 
the left hand ; the fracture being at the proximal end of the bone, and 
at the junction of the epiphysis with the shaft. 

The finger was so much swollen at first, that no dressings were ap- 
plied until the fifth day, at which time a gutta-percha splint was 
moulded to it carefully. It resulted in a perfect cure. 

I have never seen the fragments much overlapping, except in one 
instance. Frequently there has been no perceptible displacement what- 
ever; but generally there will be found a slight displacement in the direc- 
tion of the diameter of the bone. 

The case to which I refer as presenting an extraordinary overlapping, 
was that of an Irish laboring woman, aged about thirty-five years, who, 
having fallen down a flight of steps, broke the first phalanx of the 
thumb below its middle. Dr. Congar was first called on the day fol- 
lowing the accident, but was unable to reduce the fracture, and on the 



348 FRACTURES OF THE FINGERS. 

same day invited me to see the patient with him. The distal fragment 
was displaced backwards, overlapping the proximal fragment a little 
more than onc-qnarter of an inch. We made repeated eiforts, by pull- 
ing upon the thumb with a sliding noose, and with all the strength of 
our four hands, but to no purpose. The fragments could not be re- 
duced for one moment ; and we left the patient as we had found her, 
only somewhat the worse for our violent and repeated extensions and 
manipulations. The finger was already considerably swollen when we 
began our eiforts, and we cannot therefore say what might have been 
accomplished at an earlier moment, but I confess that our defeat was 
unexpected, and does not seem to me to be satisfactorily explained. 

Results. — At least ten have left no appreciable lameness or deformity, 
and possibly several more. It is therefore probably true that these 
consequences may be avoided with proper care in one-half of the ex- 
amples in which we attempt to save the finger; and perhaps it will 
occasion surprise that a perfect result may not be claimed in a larger 
proportion ; but when we consider how frequently the accident is com- 
pound, and that even when it is not, the blow having generally been 
received directly upon the point of fracture, how promptly swelling 
ensues, it will be easily understood that it will be often found difficult 
to determine whether the bone is exactly in line or not, or to maintain 
it in this position after absolute coaptation has been once secured. 

I have seen the finger in two or three cases deviate laterally, or be- 
come permanently deflected to one side or the other ; and once I have 
found it united, but rotated on its own axis. This latter case is not 
without instruction. 

A girl, set. 6, had her little finger caught by a door violently shut, 
breaking one of the phalanges, and nearly severing the finger. I closed 
the wound, and dressed the finger with a moulded pasteboard splint. 
My dressings were repeated often, and applied carefully; nor did I 
detect the rotation which the lower fragment had made upon its own 
axis until the union was consummated. I then found the extremity of 
the finger turned so that its palmar surface presented diagonally to- 
ward the ring finger. 

If the surgeon believes that this ought to have been prevented, and 
that the result evinces a lack of skill or of care, its record may still 
serve one of the purposes for which it was designed, and secure to the 
patient sometimes hereafter more faithful and assiduous attention. 

Treatment — Boyer, and after him Bransby Cooper, have taught that 
when the extreme phalanx is broken, from the small size of the bone, 
and from its having attached to it the nail and its matrix, it is better 
in all cases to amputate at once, as the process of reparation is in such 
case extremely slow and uncertain. 

"Whether in any of the cases treated by myself, or which have been 
seen by me, the fracture involved the last phalanx, I am not now able 
to say, but my impression is that such cases have come under my 
notice which have been successfully treated, and I cannot but regard 
the rule established by these gentlemen as much too stringent. Ex- 
amples must, no doubt, sometimes occur, in which the fracture is so 
simple in its character as to render prompt reunion pretty certain; and 
even though the restoration should prove tedious, this ought scarcely 



FRACTURES OF THE FINGERS. 349 

to be regarded as a sufficient justification for so serious a mutilation 
as these surgeons propose, since the loss of even an extreme phalanx is 
not only a deformity, but must prove in many occupations a trouble- 
some maiming. 

Prof. J. Lizars, of the Toronto school of medicine, C. W., has re- 
ported to me a case exactly in point. " A man in the employ of the 
Toronto Rolling Mills Company fractured the distal extremity of the 
ring finger of the right hand. The fracture was transverse, and the 
nail was severely bruised, the accident being caused by a direct blow. 
Crepitus distinct. A dorsal splint and bandage were applied, and in 
a short time the fragments were united firmly by bone. The nail 
subsequently fell off, and a new one was formed." 

The rule ought still to be held inviolate, which surgeons have so 
often repeated in reference to injuries inflicted upon the hand and 
fingers, namely, that we should save always as much as possible. 

It is remarkable, too, how much nature, assisted by art, can do 
toward the accomplishment of this purpose. If the bone of a finger 
is not only severed completely, but also all of its soft coverings, save 
only a narrow band of integument, are torn asunder, a chance remains 
for its restoration. And it is especially interesting to observe what 
recuperative powers are possessed by the articular surfaces of these 
smaller joints, so that although they may be broken into, or sawn 
through, or comminuted, and although small fragments be entirely 
removed, a complete restoration of their functions is sometimes per- 
mitted. I have seen and reported some such examples. It is true, 
however, that such fortunate results are rare, and they are rather to be 
hoped for than anticipated. 

Since, in the case of these delicate bones, the slightest deviation from 
the natural form or position determines in the end an ugly deformity, 
it becomes exceedingly 
necessary, especially with FlG - 12 °- 

females, that we should ....- — : <\ "*"y^ . 

open the dressings and ex- 
amine the fingers care- 
fully from clay to day, so 
that, as the swelling sub- 
sides, we may discover and 
correct any displacement 
which may happen to 
exist. 

As a Splint, I have found Gutta-percha, splint for finger. 

nothing so convenient as 

gutta-percha, moulded accurately to either the dorsal or palmar aspect 
of the finger ; and the form of which I have found it generally neces- 
sary to change slightly every third or fourth day, until consolidation is 
nearly or quite completed. 

If the fracture is near or extends into a joint, the finger ought to be 
a little flexed so as to place it in the most useful position in the event 
that anchylosis should occur ; and as early as the end of the second 
week the joint surfaces should be slightly moved upon each other, in 
order to the prevention of fibrous or bony adhesions. Nor is there 




350 FRACTURES OF THE PELVIS. 

much clanger of preventing the union of the bone by moving the joints 
at this early clay. Union occurs between these fragments very speedily, 
and I have never met with a case of non-union of the phalanges, nor 
do I remember to- have seen a case reported. 

It is the lateral inclination of the distal end of the finger which, 
according to my experience, it will be found most difficult to obviate, 
and which may, perhapsy, in some cases be most successfully combated 
by laying the two adjoining sound fingers against the broken finger, 
and then applying a moulded splint to the palmar surface of the whole. 
In other cases it will be more convenient to apply the splint only to 
the broken finger.. 

Rotation of the lower fragment on its own axis is especially to be 
guarded against, as the- deformity which it occasions is more unseemly, 
and the impairment of utility more decided, than that occasioned by a 
lateral deviation. 

It may be well also to remand the surgeon of the convenience of ex- 
tending the splint beyond the end of the last phalanx, and moulding 
it to this extremity, in order that the finger may be protected against 
injuries, and that when, from time to time, the splint is removed, it 
may be reapplied with accuracy. 

In all cases the splint should be lined with cotton cloth,. soft flannel, 
or patent lint, and secured in place with narrow and neatly cut cotton 
rollers. Bandages of this -width, should never be torn,, but carefully 
eut with scissors. 



CHAPTER XXVIL 

FRACTURES OF THE PELTIS, AND TRAUMATIC SEPARATIONS 
OF ITS SYMPHYSES. 

Development of ike 0& Innominatum. — This bone is formed from 
eight centres, three of which are called primary, and five secondary. 
The three primary centres belong respectively to the ilium, ischium, 
and pubes, and by their extension form eventually the greater portion 
of the innominatum. They have a common point of union in the 
acetabulum; and the ischium unites with the pubes, also, by the junc- 
tion of their rami. These conjunctions occur usually between the 
fifteenth and twentieth years of life. The secondary centres do not 
begin to ossify until the age of puberty, and may therefore properly be 
considered as epiphyses. One forms the crest of the ilium ; one its 
anterior inferior spinous process ; one forms the symphysis pubis ; one 
the tuberosity of the ischium ; while the fifth constitutes the centre of 
the bottom of the acetabulum. The epiphyses become joined to the 
primary bones, or the bodies of the innominata, at about the twenty- 
fifth year. 

1 1. Pubes. 

Lente, in his reports from the New York Hospital, mentions the 
case of a young man, set. 18, who was crushed between a couple of 



PUBES. 



351 



cars, in consequence of which he died two days after. The autopsy 
disclosed a separation of the symphysis pubis, unaccompanied with 
any other fracture. The right side was displaced backwards about 
half an inch, so that the fingers could be passed between the bones. 
There w T as also a wound in the top of the bladder large enough to admit 
the thumb. 1 Similar accidents have been several times met with by 



Fig. 121. 



Ore 




Development of the os irmominatuin. (From Gray.) 



surgeons. Hall reports a case in the Provincial Medical and Surgical 
Journal, May 1, 1844, in which the pubes, thus separated, was actually 
thrust into the bladder; but in this example the ilium was broken also. 
I need scarcely add that this patient died ; 2 but Sir Astley Cooper has 
furnished us with an example of a simple fracture or traumatic separa- 
tion at the symphysis, from which the patient after a long time almost 
completely recovered. The following is Sir Astley's account of the 
case: 

"Case 79. Richard White, set. 22, was admitted into Guy's Hospital 
on the 30th of July, 1832, having sustained a severe injury in conse- 
quence of a large quantity of gravel having fallen upon his back while 
in the act of stooping. It knocked him down ; and on rising, which 
he did with considerable difficulty, he attempted to walk ; this produced 
violent pain in the region of the bladder, extending upwards in the 



1 Lente, New York Jonrn. Med., 2d ser., vol. iv, p. 286. 

2 Hall, Amer. Journ. Med. Sci., vol. xxxiv, p. 248. 



352 FRACTURES OF THE PELVIS. 

course of the ureters to the kidneys. Upon inquiry, he stated that 
the urine he had voided since the accident was bloody and passed with 
difficulty. 

"On examination, a fissure was found at the symphysis pubis, pro- 
ducing a separation of about two fingers' breadth. On pressure being 
made upon any part of the ilium, he complained of increased pain in 
the region of the pubes, and of numbness down the left thigh. 

"A catheter was immediately passed, and the urine which was drawn 
off was clear and healthy. Leeches were applied over the pubes, and 
a broad belt was firmly buckled around the pelvis sufficiently tight to 
bring the separated pubes nearly in contact, and the patient ordered 
to be kept perfectly quiet in the recumbent posture, on low diet. The 
leech-bites ulcerated, and some slight degree of fever resulted, which, 
however, readily yielded to the usual treatment. 

"He remained in the hospital for three months without any check 
to the progress of his cure; the length of time it required being accounted 
for by the difficulty of reparation in the amphiarthrodial articulation ; 
and when he left there was some slight separation of the pubes remain- 
ing ; nor were the two lower extremities, or the anterior and superior 
spinous processes of the ilia, perfectly symmetrical, although he could 
walk very well." 1 

Malgaigne has collected four cases of simple separation at the sym- 
physis pubis occasioned by external violence, and in three of the four 
cases it was occasioned by pressing out the thighs with great force ; the 
separation being directly due, therefore, to muscular action. 

Two of these patients succumbed to the accidents. The same author 
has brought together, also, seventeen cases of separations of this sym- 
physis occurring in childbirth, of which only seven survived. 

It is much more common, however, to find the pubes broken through 
its horizontal or ascending ramus; and Clark, of the Massachusetts 
General Hospital, has described a case of simultaneous fracture of the 
pubes and ischium in three places. The man, set. 29, had been caught 
between two heavy timbers, and on the following day, May 7, 1852, 
he was brought to the hospital. 

No crepitus could be detected, but he was unable to lie upon the 
right side, and the right limb was nearly paralyzed. It was evident 
that the bladder or urethra had been ruptured, and on the third day 
Dr. Clark opened the bladder through the perineum, evacuating a large 
amount of blood and urine, and affording to the patient very sensible 
relief. On the 1st of June, however, he died, having survived the 
accident twenty-five days. 

The autopsy disclosed several fractures, all of which belonged to 
the right os innominatum. First, a fracture of the pubes near the 
symphysis ; second, a fracture near the junction of the pubes and ilium ; 
third, a fracture through the ramus of the ischium anterior to the tube- 
rosity. 2 

Sir Astley mentions a case (Case 83) of fracture of the "ramus of the 

1 Sir Astley Cooper, Frac. and Disloc., Amer. ed., p. 144. 

2 Clark, Boston Med. and Surg. Journ., vol. liii, p. 185. 



PUBES. 



353 



Fig. 122. 




Clark's case of fracture of the pelvis. 



pubes," unaccompanied with injury to the bladder or urethra, which re- 
sulted in a complete recovery; and in another case (Case 84) the patient 
recovered in eight weeks, and was 
able to walk nearly as well as before ; 
but he soon after died of disease of 
the chest. The os pubis was found, 
at the. autopsy, to have been broken 
in three places; there was also a 
fracture extending in two directions 
through the acetabulum, with an 
extensive comminuted fracture of 
the ilium, accompanied with great 
displacement. 

Marat has even found it neces- 
sary, after a fracture, to remove 
nearly the whole of the body of the 
pubes by incision, in a girl of 18 
years, and who not only recovered 
completely, but having subsequently 
married, she gave birth to two chil- 
dren in easy and natural labors. 1 

Cappelletti relates that a man, set. 54, jumped from a carriage, the 
horses having run away, and alighted with his feet to the ground, but 
with one limb in the greatest possible degree of abduction. A surgeon, 
who saw him immediately, found an enormous swelling at the superior 
part of the thigh, accompanied with very acute pain. When seen by 
Cappelletti, at Trieste, six months after, there still remained a slight 
swelling near the ramus of the ischium and pubes, under which a 
careful examination detected a fragment of bone two and a half inches 
long and of the " size of the finger." The patient w T as able to walk, 
but not without pain and limping. Cappelletti soon began to suspect 
that this fragment of bone consisted of a part of the ramus of the 
ischium and pubes detached by muscular contraction. On examining 
it anteriorly he found this part of the pelvis defective, and the loose 
portion of the bone had all of the anatomical characters of the defective 
part. He felt distinctly the circular projection indicating the point 
where the ascending branch of the ischium unites with the descending 
branch of the pubes. 2 

Whitaker, of Lewistown, N. Y., saw the body of the left os pubis 
broken in a female while in the seventh month of pregnancy. She had 
fallen down a pair of stairs, striking astride the edge of an open, upright 
barrel. The fracture w r as oblique, and with but little displacement, 
yet she complained of excruciating pain in the left pubic region on the 
least motion. The accident was followed by no positive attempt at 
miscarriage. 3 

The danger in these accidents consists not so much in the fracture, 



1 Marat, from Malgaigne, op. cit., p. 646. 

2 Cappelletti, Banking's Abstract, No. viii, p. 83; from Giornale per servire al 
Progressi della Patologie della Terapeutica, 1847. 

3 Whitaker, Amer. Journ. Med. Sci., July, 1857, p. 283. 



354 FRACTURES OF THE PELVIS. 

as iii the injury done to the bladder and other pelvic viscera. If the 
bladder is opened into the peritoneal cavity, death is almost inevitable; 
and even when the bladder or urethra has suffered laceration lower 
down or at any point above the deep perineal fascia, extensive urinary 
infiltrations, followed by abscesses and gangrene, generally expose these 
patients to the most imminent hazards. 

The practice pursued at Guy's Hospital in the case of separation at 
the symphysis pubis, commends itself both by its simplicity and by its 
success. Antiphlogistic remedies steadily pursued, rest in the recum- 
bent posture, the use of the catheter when necessary, and in certain 
cases the girding the pelvis with a firm belt or band, are measures 
which seem to meet all of the important indications. 

If the fracture is accompanied with displacement it will be proper 
to attempt to restore the fragments, but except in the case of separa- 
tion at the symphysis very little aid can be expected from a band or 
any similar means in retaining them in place. It will be sufficient, 
generally, in such examples to place the patient quietly upon his back, 
with his thighs flexed upon his body, and to treat the accident in all 
other respects as a case of inflammation. 

If the urine has become extravasated underneath the pelvic fascia, 
no time ought to be lost in opening freely through the perineum, and 
in extending the incisions, if necessary, into the urethra and bladder. 

I 2. Ischium. 

When speaking of fractures of the pubes, we have already noticed 
some examples of fractures of the ischium also ; indeed it is seldom 
that one of the bones of the innominatum is broken without a coinci- 
dent fracture of one or both of the others. The records of surgery 
furnish several other examples, produced generally by a fall upon the 
tuberosities ; but, perhaps, the most remarkable instance is that men- 
tioned by Marat as having occurred in a female during labor. 

The following summary of a case of fracture of the ischium, reported 
by Sir Astley Cooper, will serve to illustrate one of the most fortunate 
terminations of these accidents when accompanied with a rupture of the 
urethra: 

A young man who was driving a cart, was thrown down and a 
wheel passed over him. On the following morning he was found to 
have a fracture of the left leg and a contusion of the inner side of the 
left thigh. There was also great swelling and ecchymosis of the scro- 
tum, with a slight appearance of injury over the pubes and left hypo- 
chondrium. No fracture of the pelvis was at that time discovered. 
The patient was suffering great pain, and was cold and exhausted. 
Bloody urine escaped from the bladder. On the eighth day an abscess 
had pointed on the left side of the perineum, which, being opened, dis- 
charged a great quantity of pus having the odor of urine; extensive 
sloughing occurred, and the patient sank very low. On introducing 
the finger into the wound, the ascending ramus of the ischium could 
be distinctly felt, and the fracture traced in an oblique course, the 
upper fragment being slightly displaced forwards. When the catheter 



ilium. 355 

was introduced into the urethra it was found to enter this wound, and 
could be felt resting against the naked bone. From this time until 
the twenty-sixth day, the urine continued to escape freely through the 
wound. In about six weeks more the fistulous opening had entirely 
closed, and after several months his recovery was complete. 1 

The signs of this accident are generally even more obscure than those 
of fracture of the pubes, but in a case of doubt the bones ought not 
only to be carefully examined from without, but the finger should be 
introduced freely into the rectum and the anterior surface explored; or 
the tuber ischii may be grasped between the thumb and finger and 
moved laterally in order to determine the existence of motion or crepi- 
tus. If the patient is a female, this exploration can be best made 
through the vagina. By flexing and extending the thigh, also, crepi- 
tus may sometimes be discovered. The examination will generally be 
made while the patient lies upon his back; but if turning is not found 
too painful, it will be well to lay him upon his face, that the tuberosi- 
ties of the ischium may be more plainly brought into view. 

A considerable proportion of the fractures of both the pubes and 
the ischium are accompanied with lesions of the bladder or of the 
urethra, either of which circumstances will render the prognosis very 
unfavorable; but in simple fractures recoveries may generally be ex- 
pected, yet only after a tedious confinement. 

It is not usual, except in cases which must almost necessarily prove 
fatal, to find much displacement of the fragments; nor is it probable 
that by any manoeuvres the slight displacements which are found to 
exist can be entirely overcome. Instances may occur, however, in 
which careful pressure from without, or the introduction of a finger 
into the rectum or vagina, may aid in the restoration. 

The posture best suited to these cases will be indicated usually by 
the sensations of the patient himself. Ordinarily he will prefer to lie 
upon his back with his thighs flexed and supported by pillows; and 
his hips slightly elevated by a firm cushion laid under the upper part 
of the sacrum. His knees ought also to be gently bound together; 
but if the patient finds this position painful or excessively irksome, as 
sometimes he will, he may be permitted to occupy any position which 
he finds most comfortable. 

I 3. Ilium. 

Fractures of the ilium are much more common than fractures of 
either the ischium or pubes, and they assume a great variety of forms, 
directions, and degrees of complication. 

In the two following examples the anterior superior spinous process 
alone was broken off: 

John Kelly, set. 36, admitted to the Hospital of the Sisters of Charity, 
Dec. 28, 1852, having just fallen and broken the anterior superior 
spinous process of the ilium. The fragment was displaced downwards 
about one-quarter of an inch. Motion and crepitus distinct. A slight 

1 Sir A. Cooper, by Bransby Cooper, Amer. ed., p. 140. 



356 FRACTURES OF THE PELVIS. 

ecchymosis existed over the point of fracture, and other signs of con- 
tusion about the hip were present. He was intoxicated at the time of 
the accident, and could not tell how or where he fell. 

He was laid upon his back in bed, with his thighs flexed upon his 
body ; and in this position we attempted to reduce the fragment and 
retain it in place with a bandage, but finding this impossible, we left 
him with only instructions to remain quietly in bed. In about two 
weeks the fragment was firmly fixed in its new position, and he was 
allowed to get up and walk about, which he was able to do without 
inconvenience. 

July 13, 1853, Matthias Morrison was caught under a bank of fall- 
ing earth, and on the following day Dr. Mixer, his attending surgeon, 
requested me to see the case with him. He was unable to stand upon 
his feet. There was a lacerated wound and an extensive bruise on his 
left hip ; but the thigh was not shortened nor everted, and he could 
flex it slightly upon his body. Noticing a swelling and discoloration 
in the region of the anterior superior spinous process of the ilium, I 
pressed upon it and felt it recede with a distinct crepitus ; the fragment, 
however, immediately resumed its place when the pressure was re- 
moved. I was able also, by a careful manipulation, to trace the line 
of fracture, and to determine that it included a small portion of the 
anterior extremity and wing of the pelvis. 

We directed the patient to remain quietly upon his bed with his legs 
drawn up. He soon recovered, but I am unable to say what is the 
present position of the fragment. 

More frequently, however, the fracture involves a still larger portion 
of the crest, as in the following examples : 

Joseph Joquoy, set. 40, was^ caught by the bumpers between two 
cars, Feb. 10, 1854, breaking obliquely the anterior superior portion 
of the ilium. I saw him within an hour, and found him greatly pros- 
trated; the fragment of the pelvis broken off was quite movable, and 
crepitus was easily detected. His abdomen was very tender and slightly 
bloated. 

He was laid upon his back with his legs drawn up, and hot fomenta- 
tions of hops and vinegar were directed to be applied to his belly. He 
also took one grain of morphine. The broken ala did not seem dis- 
posed to become displaced. With no other treatment, his recovery was 
rapid; and the bones seemed to have united without displacement. 

James Roche, set. 41, fell March 7, 1854, from a height of fourteen 
feet, breaking off the anterior superior portion of the right ala of the 
pelvis. On the following day, I found him at the hospital of the 
Sisters of Charity. The fragment, which was quite large, was movable, 
and occasionally a crepitus could be detected. It was displaced down- 
wards and forwards about three-quarters of an inch. 

He was laid upon his back, with his thighs and legs moderately 
flexed. At the end of two weeks he found himself able to walk with- 
out much difficulty, and he immediately left the hospital. At this 
time the fragment was displaced in the same manner and direction as 
at first, but I cannot say whether it had united or not. 

I have three other similar cases upon my records ; but in the last 



ilium. 357 

example, the sixth, which has been especially recorded, the fracture 
was caused by muscular action. William Alexander, set. 70, on the 
5th of September, 1869, after riding in a railroad car about half an 
hour, arose to leave his seat, when he felt "something wrong" in his 
right groin, and found himself unable to walk without great pain. He 
was admitted to Bellevue Hospital on the same day, and I found a 
fracture involving about three inches of the ilium, including the ante- 
rior superior spinous process. It was inclined to fall outwards, but was 
easily replaced with a distinct crepitus. 

I have once seen a fracture of the posterior superior spinous process, 
and I do not know of any other example. 

Miss B., set. 19, was thrown from her horse backwards, striking with 
her back upon the ground. She was first attended by Dr. Coan, of 
Ovid, X. Y., and she did not come under my care until two weeks 
after the accident. 

I found a small fragment broken from the posterior superior spinous 
process of the ilium, and displaced backwards in the direction of the 
spine about half an inch. It was movable, and by pressure it could 
be partially restored to place, but it would immediately return to its 
abnormal position when the pressure was removed. The injured hip 
was painful, and occasionally it felt numb. She had previously suf- 
fered from spinal irritation. 

I laid a compress behind the fragment, and secured it in place with 
a roller, enjoining perfect rest. She recovered from her lameness in 
a few weeks, but I believe the fragment remains displaced. 

Extensive comminuted fractures of the ilium are generally accom- 
panied with so much injury of the pelvic viscera as to prove rapidly 
fatal ; but the following example will show that this rule admits of 
exceptions. 

June 5, 1854, Bernard Duffle, set. 32, was crushed under a very 
heavy stone which fell upon his back. I found the left ala of the 
pelvis broken into several fragments, between the different portions of 
which motion and crepitus were distinct. The fractures were near the 
superior part of the bone, commencing about two inches back of the 
anterior superior spinous process, and extending backwards irregu- 
larly. There was a narrow wound communicating with the fracture, 
from which I removed a loose fragment of bone. The right leg was 
also broken. 

Four months after, he was still confined to his bed, and a fistulous 
opening continued opposite the point of fracture ; there existed also 
a large and irregular mass of ossific matter or callus around the frag- 
ments. He soon after left the hospital. 

Dr. Sargent, of the Massachusetts General Hospital, has reported a 
case in which a man received a compound fracture of the left ilium, 
and several small fragments were removed. He was discharged at 
the end of three months with a fistulous opening still remaining, but 
in other respects he was quite well. 1 Dr. Cheever, of the same hos- 
pital, reports a case of fracture of the ilium, with fracture of the ascend- 

1 Sargent, Boston Med. and Surg. Journ., vol. liii, p. 121. 



358 FRACTURES OF THE PELVIS. 

ing ramus of the pubes, resulting in complete recovery ; but the leg 
became shortened and the toes inverted. Dr. Cheever believes that the 
lines of fracture met in the acetabulum. 1 

The following case illustrates the more fatal injuries of this char- 
acter : 

John O'Keaf was crushed under a heavy stone, Oct. 23, 1851, break- 
ing and comminuting the alse of the pelvis on both sides, and wound- 
ing also the iliac vein. He was taken to the hospital of the Sisters of 
Charity, and died in a few hours, partly from the shock to his system, 
and partly from the haemorrhage. 

Lente, of the New T York Hospital, has reported a case of dislocation 
of the hip, which was accompanied with a fracture also of the ala of 
the pelvis upon the same side. The dislocation was reduced on the 
third day, and the patient soon after died. The autopsy disclosed 
what had not been suspected during* life, namely, that the left ilium 
was broken horizontally about through its middle, and vertically 
through the crest; and also that there was a fracture extending through 
the sacro-iliac synchondrosis, accompanied with considerable commi- 
nution of the articular surfaces. It was also found that a portion of 
the small intestine was ruptured, and probably by one of the sharp 
fragments of the broken pelvis. 2 

It is seldom, I think, that the fragments become much displaced ; 
such, at least, has been my experience ; and I have noticed in Dr. 
Neill's cabinet three specimens of fracture of the crest of the ilium, all 
of which had united without any appreciable displacement. Dr. Neill 
also called my attention to the fact that in two of these specimens the 
ensheathing callus was confined to the outer surface of the bone; an 
observation which, this gentleman assures me, he has had frequent 
occasion to make before where the fracture belonged to a flat bone. 

If any displacement exists, the upper or loose fragment is generally 
carried slightly inwards ; occasionally, however, it is found displaced 
upwards, outwards, or downwards. 

Treatment. — In a large majority of cases the fragments, if displaced, 
cannot be completely replaced. Occasionally, however, as where the 
anterior superior spinous process is broken off with only a small por- 
tion of the crest, the fragment may be seized with the fingers and car- 
ried outwards or upwards, or in whatever direction may be necessary; 
but to retain it in this position is generally quite impossible. The 
bandage or broad belt which we have recommended in certain fractures 
of the pubes would be in these cases not only useless, but absolutely 
mischievous, since its effect must be to press inwards the fragments, 
and thus to create a displacement which might not otherwise exist. 

The surgeon ought to determine by a careful examination the extent 
and direction of the fracture, and, having done what was in his power 
to replace the fragments, he should lay his patient upon his back with 
the thighs drawn up and supported. This is the position which will 
generally be found most comfortable; but, as in other fractures of the 

1 Cheever, Bost. Med. and Surg. Journ., May 3, 1866. 

2 Lente, New York Journ. of Med., Jan. 1851, p. 29. 



ACETABULUM. 359 

pelvis, it may be well always to try the effect of other positions, and 
especially to determine their influence upon the fragments, and finally 
to adopt that precise posture which accomplishes the indications best. 

If the fracture is compound, and the fragments have penetrated the 
belly, the wound should be enlarged, and, as far as possible, every 
piece of bone should be removed ; but if the fragments cannot be found, 
the external opening should be allowed to remain so as to favor their 
escape when suppuration shall have taken place. 

I 4. Acetabulum. 

Although, strictly speaking, fractures of the acetabulum belong 
always to one or all of those bones of the pelvis whose lesions have 
already been described, yet the peculiar relations of this cavity to the 
femur render it necessary that they should be considered as a separate 
class of accidents. 

Fractures of the acetabulum divide themselves naturally into two 
varieties. 

First. Fractures of the base of the cavity, with or without displace- 
ment. 

Second. Fractures of the rim, with or without displacement. 

In fractures of the base of the cavity, not accompanied with displace- 
ment, nothing but crepitus can be present as a sign of the accident ; 
and this will scarcely be sufficient, in itself, to enable the surgeon to 
distinguish it from a fracture of the neck of the femur within the cap- 
sule without displacement. 

It is probable, therefore, that its existence will only be determined 
by dissection. JSTor is it of much importance that the diagnosis should 
be made out; since in either case neither splints nor any other surgical 
appliances could be of service. An injury so severe as to fracture the 
acetabulum will necessarily so much bruise the body, and concuss the 
viscera of the pelvis, as to compel the patient to remain quiet for a 
number of days, and this is all that would be thought necessary if the 
nature of the accident was exactly determined. 

Dr. NeilPs cabinet contains a specimen of this kind, in which the 
fracture, commencing near the centre, extends in three directions across 
the cotyloid margins, and in which perfect bony union has occurred 
without displacement. 

M. Bouvier related to the Academy the case of a man, set. 71, who, 
in consequence of a fall from his bed, remained for three weeks unable 
to walk, and never was able afterwards to w r alk without crutches. No 
fracture could be discovered during life, but after his death, which 
occurred some months subsequent to the accident, a fracture was found 
extending from the ilio-pectineal eminence to the spine of the ischium, 
and traversing the centre of the acetabulum. The fragments were not 
displaced, but remained slightly movable. 1 

The following case was reported by Mr. Earle, to the London 

1 Bouvier, Araer. Journ. Med. Sei., vol. xxiii, p. 486; from Bullet, de l'Acad. 
Roy. de MeU, August 15, 1838. 



360 FEACTURES OF THE PELVIS. 

Medico-Chirurgical Society, and will be found in the nineteenth 
volume of its Transactions. It is also referred to by Sir Astley, in his 
Treatise on Fractures and Dislocations. 

In the month of October, 1829, a man, set. 40, was admitted into 
St. Bartholomew's Hospital, with a severe injury, caused by having 
fallen from a height of thirty-one feet and striking upon the left side. 
The left leg was powerless and shortened. The foot was everted. 
Any attempt to rotate the limb caused great pain, and was accom- 
panied with a sensible crepitus. The left trochanter was very much 
depressed, and when it was pressed upon, the patient complained of 
deepseated pain in the hip-joint. 

He recovered in eight weeks, and was able to walk nearly as well 
as before ; but he soon after died of disease in the chest. 

On dissection, a fracture was found extending in two directions 
through the acetabulum; there was an extensive comminuted fracture 
of the ilium, with great displacement, and the os pubis was broken in 
three places. 

The repair was very complete, and Mr. Earle remarked how nature 
had guarded against any considerable deposit of new bone within the 
articulation, which might have interfered with the functions of the 
joint, while there was an abundant deposit of callus around the other 
parts of the fractured bone. 

Mr. Travers has reported two similar cases, and in the paper accom- 
panying the report he maintains that very acute pain caused by press- 
ing upon the projecting spine of the os pubis, and the inability of the 
patient to maintain the erect posture, may be regarded as signs diag- 
nostic of the accident. 1 It is doubtful, however, whether these phe- 
nomena, so common to many other accidents, could be relied upon as 
evidence of this peculiar lesion. 

Fractures of the base of the acetabulum, with displacement of the 
femur into the pelvic cavity, constitute a much more formidable, and 
unfortunately a more common form of accident. 

Like the preceding variety of acetabular fractures, they are produced 
generally by falls upon the trochanter major, but the force of the con- 
cussion has been greater. 

Even here, it is not often that the diagnosis has been clearly made 
out during life; and indeed, generally, the true character of the acci- 
dent has not even been suspected, the surgeons believing that they bad 
to do with a fracture of the neck of the femur, or with a dislocation. 
In two examples (Cases 71 and 72) mentioned by Sir Astley Cooper 
as having been presented at St. Thomas's Hospital, the thigh was 
thought to be dislocated backwards. 

In the following example reported by Lendrick, of Dublin, the patient 
was supposed to have a fracture of the neck of the femur: 

An old man, well known as the " Wandering Piper," was admitted 
into the Mercer Hospital in January, 1839, suffering under phthisis 
pulmonalis and acute inflammation of the hip-joint. Some years be- 
fore, he had received a severe injury by the upsetting of a coach, and 

1 Travers, Holmes's System of Surgery, vol. ii, p. 478. 



BASE OF THE ACETABULUM. 361 

was under treatment several months for what was supposed to be a 
fracture of the neck of the femur. Since that time he had been lame, 
but still able to take a great deal of exercise on foot both in Great 
Britain and in America. The acute disease of the joint commenced 
about two months before his admission, and he was at first under the 
care of Sir Philip Crampton, who remarked that the thigh was only 
shortened about half an inch, and expressed his surprise at this fact. 

This man died on the 17th of February, and the dissection showed 
that there had been no fracture of the femur, but its head and neck 
were affected with u morbus coxae senilis." The head was also thrust 
through a rent in the acetabulum into the cavity of the pelvis ; but the 
head had again been covered by a bony case, complete, except in a 
small portion about the size of a shilling piece, and at this point the 
covering was ligamentous. 

The os pubis had also been broken at the same time, and it had 
united so much overlapped that the space between the inferior anterior 
spinous process and the symphysis pubis was shortened nearly an inch. 
A portion of intestine was found protruding through an opening in the 
pelvis and adherent to the bone, in which situation it seemed to have 
been caught by the broken fragments and retained. 1 

Morel-Lavallee, in his thesis upon complicated luxations, mentions 
a case which had come under his observation, and which had been 
treated as a fracture of the neck of the femur. The patient survived 
the accident many years; during a part of which time he suffered such 
pain in the hip-joint as to induce a belief that it was itself diseased. 
At his death he was found to have had a multiple fracture of the bones 
of the pelvis, and the head of the femur had penetrated more than an 
inch into the cavity of the pelvis, pressing upon the obturator nerve to 
such a degree as to have, no doubt, caused the severe pain from which 
he had suffered, and which had been ascribed to coxalgia. 2 

In the two cases mentioned by Sir Astley Cooper as having been re- 
ceived into St. Thomas's Hospital, the toes were turned in. In the 
example mentioned by the same author as having been presented at St. 
Bartholomew's Hospital, the toes were everted ; the two persons seen by 
Lendrick and Morel-Lavallee were supposed before death to have had 
a fracture of the neck : it is probable, therefore, that in both of these 
cases the toes were also everted ; while Moore has dissected a subject 
whose pelvis was broken into many fragments — the left os innomina- 
tum was divided into three portions, corresponding to the three bones 
of which it was composed in infancy ; the head of the femur had com- 
pletely penetrated the basin; the limb was shortened two inches, and 
in a position of slight flexion and adduction, but neither rotated out- 
wards nor inwards. 3 

There seems, therefore, to be no certain rule in relation to the posi- 
tion of the limb ; but it is found to take the one position or the other, 

1 Lendrick, Amer. Journ. Med. Sci., vol. xxiv, p. 481; August, 1889; from 
London Med. Gazette, March, 1839. 

2 Morel-Lavallee, from Malgaigne, op. cit., vol. ii, p. 881. 

3 Moore, Med.-Chir. Trans., vol. xxxiv, p 107, 1851. 

24 



362 FRACTURES OF THE PELVIS. 

probably according to the direction of the force which has inflicted the 
injury, and perhaps in obedience to circumstances not always easily ex- 
plained. 

The shortening has been observed to vary from half an inch to two 
inches or more ; the trochanter is also usually driven in toward the 
pelvis. Pressure upon the trochanter occasions a deepseated pain. If 
the limb is drawn down to the same length with the other, it immedi- 
ately resumes its position when the extension is discontinued. Crepi- 
tus is more uniformly present than in fractures of the neck of the femur, 
and it is especially felt while the limb is being extended or while it is 
again shortening, and not so much in flexion or rotation. 

If, in addition to all of these phenomena, we learn that the accident 
has occurred from a severe blow, or a fall from a great height upon the 
trochanter ; and that the viscera of the pelvis, and especially the bladder, 
seem to have suffered considerable injury; or if we detect at the same 
time a fracture of some other portion of the pelvis — we may reasonably 
conclude that the head of the femur has penetrated the acetabulum. 
Yet it must be confessed that no one of these symptoms is positively 
distinctive of this accident, and that they are seldom found sufficiently 
grouped to render the diagnosis certain. 

The old "piper" mentioned by Lendrick, and the man dissected by 
Morel-Lavallee, lived many years, and managed to walk about, but 
not without considerable pain ; the other three, to whom I have alluded, 
died soon after the injuries were received. 

Some have thought of treating these cases by extension and counter- 
extension ; the latter being accomplished through the aid of a perineal 
band ; but it is not probable that after an injury of this character, any 
patient will be able to endure the requisite pressure about the perineum 
or groins. It will be better to lay the patient upon Daniel's invalid 
bed, or some bed similarly constructed, so that it may be converted 
into a double-inclined plane; allowing the knees to be suspended 
over the angle thus formed, in order that the weight of the body may 
have some effect to draw away the pelvis from the femur. Or we may 
adopt extension without the perineal band, as will be described here- 
after when treating of fractures of the femur. 

Fractures of the rim of the acetabulum have frequently been dis- 
covered in dissections; and the records of surgery abound with cases 
of unreduced dislocations of the femur, in which the failure to reduce 
or to retain the bone in place has been ascribed, not always with suffi- 
cient reason perhaps, to this fracture. 

Dr. McTyer, of the Glasgow Royal Infirmary, published, in the Glas- 
gow Medical Journal for February, 1830, four cases of this fracture. 

The first was that of a man, set. 27, on whose back a number of 
bricks had fallen while he had his right knee placed on the bank of a 
trench. His right leg was found shortened about one inch and a half, 
bent, and the toes turned a little outwards. The limb could be moved 
without much difficulty, but every motion gave him pain; motion was 
also attended with crepitus. On making extension, the limb was easily 
brought to the same length with the other, but it became shortened 
again immediately when the extension was discontinued. 



RIM OF THE ACETABULUM. 363 

The symptoms, differing but little, if at all, from those which are 
usually present in a case of fracture of the neck of the femur, led to 
the supposition that this was actually the nature of the accident. Sub- 
sequently, the toes became slightly turned in, but this circumstance 
was not regarded as sufficiently distinctive to warrant a change in the 
diagnosis. 

Having succumbed to the injuries after a few days, the autopsy re- 
vealed a fracture extending through the bottom of the right acetabulum, 
and about one inch and a half of the rim at its upper and posterior 
margin completely detached, except as it was held in place by a portion 
of the capsular ligament. The head of the bone could be easily pushed 
upwards and backwards upon the dorsum, the fragment of the acetab- 
ular margin being moved aside, and swinging upon its fibrous attach- 
ment as upon a hinge, but resuming its place again perfectly when the 
head of the femur was restored to the socket. The femur was not 
broken. 

In the second case the limb was found shortened, the knee slightly 
bent, and turned a little forwards and inwards, and the toes pointing 
to the tarsus of the other foot. It was thought to be a fracture also of 
the neck of the femur, but the autopsy disclosed only a fracture of the 
upper margin of the rim of the acetabulum. 

In the third case, seen only after death, the limb was not shortened 
much, but the toes were stretched downwards, and turned slightly in- 
wards. It was supposed at first to be a simple dislocation, but on dis- 
section the posterior and inferior margin of the acetabulum was found 
to be broken and displaced towards the coccyx, while the head of the 
femur rested upon the pyriformis muscle, over the ischiatic notch. 

The fourth example was found in the dissecting-room, and the his- 
tory of the case is not known. A fragment of the superior and pos- 
terior margin of the acetabulum had been broken off, and had reunited 
slightly displaced. 1 

Several other similar examples have been established by dissection, 2 
and we are able, therefore, to determine pretty accurately what are the 
usual phenomena and termination of this accident, though we are far 
from having arrived at a satisfactorv means of diagnosis; indeed, the 
accident has seldom been recognized before death. Its causes are gen- 
erally the same with those which produce dislocations of the hip, but 
in most instances the violence has been greater than in the case of dis- 
locations. 

The symptoms are, first, such as indicate a dislocation, to which must 
be added crepitus and a difficulty, if not impossibility, of retaining the 
head of the femur in its place when it is reduced. The crepitus is 
sometimes discovered the moment we begin to move the limb, and this 
will aid us to distinguish it from a fracture of the neck of the femur 
accompanied with much displacement, since, in the latter case, crepitus 

1 McTyer, Amer. Journ. Med. Sci., vol. viii, p. 517, Aug 1831. 

2 Maisonneuve, Chirurg. Clin., 1863, p. 108. Sir Astley Cooper on Disloc. and 
Frac. 1823, second London edition, p. 15. M. Bemud, Bulletin de la Soc. de Chir., 
1862, torn, iii, p. 185. Ibid., p. 226. Bigelow on Hip-Joint, 1869, p. 139 et seq. 



364 FRACTURES OF THE PELVIS. 

is not felt usually until the extension is complete, and the fragments 
arc again brought into apposition. 

The majority of these accidents, either from a failure to recognize 
them, or from the impossibility of maintaining the head of the femur 
in place when once it has been reduced, have resulted in a permanent 
dislocation of the hip and a serious maiming. The following case was 
recognized and reduced, but it was found impossible to maintain the 
reduction. 

February 3, 1847, a strong German laborer was crushed under a mass 
of iron weighing several tons. Drs. Sprague and Loomis, of Buffalo, 
were called, and found the left thigh dislocated upwards and backwards, 
and by the aid of six men they succeeded in reducing it, the reduction 
being attended, as the gentlemen have informed me, with a slight sen- 
sation of crepitus. The legs were then laid beside each other, and the 
knees tied together, the patient lying on his back; and now the two 
limbs appeared to be of the same length. On the second and third 
days the injured limb was examined by the same gentlemen, and there 
was no displacement. On the fourth day I was invited to meet these 
gentlemen, the patient having had muscular spasms during the previ- 
ous night, and the thigh being reluxated. I found the limb shortened 
one inch and a half, adducted and the toes turned in. We immediately 
applied the pulleys, and soon drew the trochanter down to a point ap- 
parently opposite the acetabulum, and a careful measurement showed 
that the two limbs were of the same length. The pulleys being re- 
moved, the leg did not draAv up again, nor did the foot turn in, yet Ave 
had felt no sensation to indicate that the bone had slipped into its 
socket, nor had we felt crepitus. The legs and thighs were now laid 
over a double-inclined plane, and well secured. He remained in this 
condition three days more, during which time Dr. Sprague saw T him 
each day, and found nothing disarranged. On the night of the seventh 
day the spasms returned, and in the morning the thigh was displaced. 

The next day we again applied the pulleys, but soon found that the 
bone would not remain in place one minute 'after the pulleys were re- 
moved. 

At this time, w r hile moderate extension was being made at the foot 
by rotating the foot inwards, we could distinctly feel a slight crepitus. 
A straight splint w T as applied, and as much extension made as he could 
conveniently bear, and in this condition the limb was kept several 
weeks. Seven years after, I found the thigh still displaced upon the 
dorsum ilii. He limped badly, but he could walk fast, and perform 
as much labor as before the accident. 

In one case mentioned by Mr. Keate, the bone had become dislo- 
cated downwards, and could be felt lying against the tuber ischii, and 
the presence of a "distinct grating as of ruptured cartilage" led him 
to conclude that the cartilaginous labrum of the socket was broken 
off; but as the fracture was in the lower margin of the socket, no 
difficulty was experienced in retaining the bone in position. 1 

If the diagnosis is satisfactorily made out, and upon complete re- 

1 Keate, Amer. Journ. of Med. Sei., vol. xvi, p 225. 



SACRUM. 365 

duction the femur will not remain in place, the treatment ought to be 
the same as for a fracture of the thigh, except that no lateral splints 
or bandages to the thigh will be necessary. The limb ought to be 
kept drawn out to its proper length, as far as this shall be found to be 
practicable, bv extending and counter-extending apparatus. A band 
around the pelvis, so adjusted as to press the head of the bone into its 
socket, may also be of service in preventing the tendency to displace- 
ment; and in case the bone manifests little or none of this tendency, 
the hip bandage will probably alone be sufficient, yet even here no 
harm could come of applying the long straight splint and the extend- 
ing apparatus, secured moderately tight, simply as a measure of pre- 
caution. Dr. Bigelow recommends angular extension, effected by 
means of an angular splint, such for example as Nathan E. Smith's, or 
Hodgen's, suspended from the ceiling, or from some other point above 
the patient; "or," he adds, "if any manoeuvre has reduced the bone, 
the limb should be retained, if possible, in the attitude which com- 
pleted the manoeuvre." 

§ 5. Sacrum. 

Simple fractures of the sacrum, known to be exceedingly rare, 1 are 
occasioned either by such injuries as break at the same time the other 
bones of the pelvis, or by blows or falls received directly upon the 
sacrum. It may be broken at any point, and in any direction, when 
the fracture is produced by the first of this class of causes ; but if the 
fracture is the result of a fall upon the sacrum, it will generally be 
transverse, and below the sacro-iliac symphysis. The displacement in 
this latter class of cases is almost invariably the same, the coccygeal 
extremity being simply carried forwards, yet this is seldom sufficient 
to interfere in any degree with the functions of the rectum and anus ; 
but in one case seen by Bermond it nearly closed the rectum. Some- 
times, also, there is a slight lateral deviation. There is also in the 
Dupuytren museum, at Paris, a specimen in which the whole of the 
lower fragment is displaced a little forwards. 

The signs of this fracture are pain at the seat of injury, aggravated 
greatly in the attempts to flex or elevate the body, and especially in 
the efforts at defecation ; swelling and discoloration of the soft parts 
covering the sacrum ; displacement of the coccyx forwards ; an angu- 
lar projection at the point of fracture, with a corresponding retiring 
angle upon the opposite side ; mobility. 

Experience has shown that where the fracture of the sacrum is 
accompanied with other fractures of the pelvis, the patients seldom 
recover; and only because so extensive an injury implies usually great 
force in the cause which produced the fractures, and, of necessity, 
greater lesions among the pelvic viscera. Simple fractures, from falls 
upon the sacrum, occurring below the sacro-iliac symphysis, are gener- 
ally followed by speedy recoveries, although the inward displacement 
is not often completely overcome. 

1 Malgaigne has referred to eight eases ; and I have not been able to find a record 
of any others. 



366 FRACTURES OF THE PELVIS. 

By introducing a finger into the rectum, the lower fragment can be 
easily pressed back to its natural position, but the difficulty consists in 
finding any means of retaining it there until bony union is effected. 
Judes succeeded to his satisfaction with a wooden cylinder, which he 
compelled the patient to wear forty-five days ; removing it, however, 
every third day, in order to cleanse the rectum with an enema. Ber- 
mond introduced first a linen bag, which he immediately proceeded to 
fill with lint; but during the night it became necessary to remove it, 
in order to relieve the bowels of wind and stercoraceous matter. He 
now substituted a silver canula covered with a shirt, which latter he 
filled with lint in the same manner as before. This was retained 
without much inconvenience nineteen days ; having only been removed 
once during this time. The union now seemed to be firm, and the ap- 
paratus was removed. Plugging the rectum in this manner may be 
necessary whenever the inward inclination of the lower fragment is 
found to be considerable, but not otherwise; ordinarily it will be suffi- 
cient to lay the patient upon his back, with a firm cushion above the 
point of fracture, so as to prevent the bed from pressing in the lower 
fragment; and having emptied his rectum thoroughly by an enema of 
warm water, he should be placed under the influence of an opiate suffi- 
ciently to restrain the action of the bowels for several days, or for as 
long a time as may be consistent with health or comfort. To the same 
end, also, the diet ought to be light and dry ; nothing should be 
allowed which might prove laxative. By constipating the bowels, 
two ends may be gained. We shall prevent that frequent action of 
the sphincters, which might tend to disturb the union; and the hard- 
ened faeces, by their accumulation in the rectum, may serve to press 
back the lower fragment of the sacrum, in a manner much more natu- 
ral and quite as effective as any apparatus which can be contrived. 

I have already mentioned a case of separation of the bones at the 
sacro-iliac symphysis, reported by Lente, but which was accompanied 
also with a fracture of the ilium and a dislocation of the hip. Several 
other similar examples have been reported, in some of which both of 
the sacro-iliac symphyses have been separated, or displaced. Such ac- 
cidents are the results only of great violence, and the subjects of them 
seldom recover. 

Dr. J. T. Banks, of Griffin, Ga., has reported one example of com- 
plete recovery in an adult male, in which the right sacro-iliac sym- 
physis w r as separated " by a blow received upon the tuberosity of the 
ischium, driving the ilium up an inch or more, causing complete pa- 
ralysis and anaesthesia of the right leg for two or three weeks;" motion 
of the hip caused also severe pain. No attempt was made to reduce 
the bones, but union occurred, and he gradually regained the use of 
his limb. 1 In a few instances this articulation has been known to give 
way during labor, while the symphysis pubis has suffered little or no 
diastasis; and in these cases recovery has generally taken place. 

1 Banks, Atlanta Med. and Surg. Journ., May, 1866. 



FRACTURES OF THE FEMUR. 367 

In nearly all the traumatic examples reported, the diastasis has been 
accompanied with a fracture extending parallel with the margins of the 
synchondrosis ; and it is for this reason that I have preferred to con- 
sider these accidents as fractures, rather than as dislocations. 

8 6. Coccyx. 

Cloquet mentions two cases as having come under his notice, one 
produced by a kick, and the other by a fall. In the latter case one 
thigh and both legs were also broken, and the coccyx having become 
carious in consequence of the fracture, was gradually exfoliated. 1 

The symptoms, mode of diagnosis, and the treatment in case of a 
fracture of the coccyx will scarcely demand of us consideration after 
having treated fully of these points in their relation to fractures of the 
sacrum. 

It is more common, however, to meet with examples of separations 
of the coccyx from the sacrum, which may be regarded in some cases 
as veritable fractures, and in others as a species of luxation. 

Due to the same causes which produce fractures of the coccyx itself, 
its symptoms differ only in the increased length of the movable frag- 
ment, and its consequent greater projection in the direction of its dis- 
placement. If it is thrown forwards, as it usually is, the rectum may 
be almost or completely blocked up by its presence ; or, if it is carried 
backwards, its pointed extremity presses almost through the skin. 

Its mode of reduction and retention is the same as in fractures of 
the coccyx and sacrum. 



CHAPTER XXVIII. 

FRACTURES OF THE FEMUR. 

Development of Femur. — The femur is formed from five centres of 
ossification: namely, one for the shaft, commencing at about the fifth 
week of foetal life ; one for the lower end, including the condyles, com- 
mencing at the ninth month of fcetal life; one for the head, commenc- 
ing at the end of the first year after birth ; one for the great trochanter, 
commencing during the fourth year; and one for the lesser trochanter, 
commencing between the thirteenth and fourteenth years. None of these 
epiphyses are joined to the shaft until after puberty, but consolidation 
is generally completed at the twentieth year. The order in which 
union occurs is exactly the reverse of the order in which ossification 
commences, the lower epiphysis being the first to exhibit traces of ossi- 
fication, and the last to unite. 

1 Cloquet, art. Bassin, of Diet., 3d vol. 



368 



FRACTURES OF THE FEMUR. 



Fig. 123. 



Division of Fractures. — Of 156 fractures of the femur, not including 
gunshot, which have been recorded by me, 63 belong to the upper 
third, 67 to the middle third, and 26 to the 
lower third ; or, if we confine our analysis to 
the shaft alone, 23 belong to the upper third, 67 
to the middle, and 26 to the lower. 

(I have personally examined many more cases 
of fracture of the femur than are above enumer- 
ated, but these include all which have been sub- 
jected to this species of analysis.) 

Dr. Frederick E. Hyde, in his analysis of 322 
cases in Bellevue Hospital, states that 95 occurred 
in the upper third (including fractures of the 
neck); 169 in the middle third, and 38 in the 
lower third (including the condyles). In the 
20 remaining cases the point of fracture is not 
stated. 

To give a summary of these valuable tables 
more in detail, 61 belonged to the neck, of 
which 14 are stated in the records to be intra- 
capsular, 17 extracapsular, and 30 undetermined. 
Thirty-four were in the upper third of the shaft ; 
169 in the middle third, and 31 in the lower; 
the exact point of fracture of the shaft being 
undetermined in 20 ; 7 fractures belonged to the 
condyles. 1 

The femur constitutes, therefore, a striking 
exception to the rule which my observations 
have established, that in the case of the long 
bones the lower third is most often the seat 
of fracture. The femur is most often broken in its middle third, and 
generally near the upper end of this third ; that is to say, above its 
middle. 

\ 1. Neck of the Femur. 

Forty of the whole number recorded and analyzed by myself were 
fractures of the neck, either intra- or extracapsular. The youngest of 
these patients, excepting one case of supposed epiphyseal separation, 
was thirty-nine years, the oldest eighty-four, and the average age was 
about sixty. Seventeen were males and twenty-three females. All 
were simple. Thirteen were believed to be without the capsule, and 
sixteen were believed to be within ; the remainder were undetermined. 

We have already given the number of fractures of the neck, both 
intra- and extracapsular, reported in Dr. Hyde's tables. Having ref- 
erence to age, 19 years was the youngest, and 85 the oldest; 20 years 
and under presented two cases ; from 20 years to 30, five cases ; from 
30 to 40, nine ; from 40 to 50, eight ; from 50 to 60, fourteen ; from 60 




Development of femur. 
(From Gray.) 



1 Hyde, Analysis of 322 cases of Fracture of the Femur, at Bellevue Hospital, 
from 1865 to 1873, inclusive. Medical Record, 1875. 



CAPSULE. 369 

to 70, fifteen ; from 70 to 80, seven ; from 80 to 90, one. Of the whole 
number, thirty-nine were males, and twenty-two females ; none of the 
fractures were compound; fourteen are recorded as of the right leg; 
seventeen of the left ; and thirty are undetermined. Fourteen were 
diagnosticated as intracapsular, and seventeen as extracapsular, thirty 
being undetermined. 

Surgeons have differed in their opinions as to the relative frequency 
of fractures of the neck of the femur within or without the capsule. 
This has arisen, no doubt, in part from the difficulty and probable 
inaccuracy of many of the diagnoses. Malgaigne, w r ho has adopted a 
mode of deciding this question which, it must be conceded, is much 
less liable to error than simple clinical observation, namely, an exam- 
ination of cabinet specimens, finds in four large collections sixty-one 
intracapsular fractures, and only forty-two extracapsular. So that, 
according to his observations, they stand in the proportion of about 
three to two ; the intracapsular being the most common. On the con- 
trary, Nelaton believes that extracapsular fractures are much the most 
common, and Bonnet, of Lyons, affirms that they constitute the im- 
mense majority. Bonnet made four dissections, and in each case he 
found the fracture extracapsular. This testimony, so far as it goes, 
is positive, but the number is not sufficient to establish anything more 
than a probability in favor of the greater frequency of extracapsular 
fractures. 

Clinical observations are too uncertain to be made available in so 
nice a question. Cabinet specimens may have been collected for a 
special purpose, and this is well known to have been the fact with the 
celebrated Dupuytren collection, the specimens in which constitute 
nearly one-third of the whole number referred to by Malgaigne. I 
allude to the effort which was made while the controversy was pend- 
ing between Dupuytren and Sir Astley Cooper as to the probability 
of bony union in intracapsular fractures, to accumulate cabinet speci- 
mens of this fracture ; and which effort extended itself, no doubt, both 
to London and Dublin, from which sources alone Malgaigne has gath- 
ered the balance of his figures. In Dr. Mutter's collection, at Phila- 
delphia, I think there are only three examples of intracapsular fracture, 
to seven extracapsular. 

Dr. Reuben D. Mussey, of Cincinnati, has in his cabinet twelve 
examples of fractures of the neck of the femur without the capsule, and 
only ten within. 

We ought, therefore, to regard the question of relative frequency as 
still undetermined. 

(a.) Neck of the Femur within the Capsule. 

Causes. — In no other fractures do the predisposing causes play so 
important a part as in fractures of the neck of the femur, and this 
whether within or without the capsule ; indeed, experience has shown 
that without the concurrence of those pathological changes which usu- 
ally accompany old age, these fractures can scarcely occur. 

Dr. Merkel considers the fragility of the neck, within the capsule, 



370 



FRACTURES OF THE FEMUR. 



Fig. 124. 



in old persons, due to the absorption of that process of the cortical sub- 
stance which arises from about the level of the trochanter minor, and 
ends close under the head of the bone, at the anterior part of the neck ; 
thus occupying the situation where the greatest pressure is made in the 
erect position. This process he calls the " calcar femorale." In newly 
born children it is absent; it appears when they begin to walk, attains 
its greatest development in middle age, and completely disappears 
in old persons. 1 Dr. Merkel says that no account has hitherto been 
given of this process ; but this statement is scarcely correct, inasmuch 
as it has been both described and represented by various surgical and 
anatomical writers for a long time (see Fig. 127 of this volume). The 
fact of its absorption in advanced life is, however, an original observa- 
tion. 

Sir Astley Cooper thought that the majority of fractures of the neck 
after the fiftieth year were intracapsular ; but Robert Smith has given 
us the ages of sixty persons having fractures of the neck of the femur, 
and the average age of thirty-two in whom the fractures were within 
the capsule, is sixty-two years, while the average age of twenty-eight 
in whom the fractures were extracapsular, is sixty-eight years. Mal- 
gaigne has referred to this testimony in proof of the inaccuracy of the 
opinion held by Sir Astley Cooper ; but I trust it will not be regarded 
impertinent or hypercritical for us to inquire how Mr. Smith became 

possessed of the ages of all these per- 
sons from whom these specimens were 
obtained ; for more than half of the 
whole number, that is, just thirty-two, 
have their ages set down in round deci- 
mals, such as 50, 60, 70, etc., and it 
would be easy to show by the inevita- 
ble law of chances, that this could not 
possibly be a true statement. If Mr. 
Smith does not pretend to have given 
the ages with accuracy, but only to have 
arrived as near to the truth as his sources 
of information would permit, then I pro- 
test that these tables do not constitute 
proper evidence in relation to this point; 
and until better evidence is furnished I 
shall continue to think, with Sir Astley 
Cooper, that fractures within the cap- 
sule belong generally to an older class 
of subjects than fractures without the 
capsule. This opinion, confirmed by 
my own experience, does not, however, as Malgaigne seems to think, 
imply that fractures within the capsule may not occasionally occur in 
persons much younger than the average limit, namely,* under fifty 
years. 

Dr. Hyde's tables present two cases under 50 years, and twelve at 




Fracture within the capsule. 



NECK, WITHIN THE CAPSULE. 371 

or over 50. Of the two under 50 years, one was 48 years of age, and 
the other 39. Of course the reader will make what allowance he shall 
think proper as to the accuracy of these diagnoses, inasmuch as such 
diagnoses are notoriously difficult, and often inaccurate. 

It is also believed that intracapsular fractures are more frequent in 
women than in men. In Dr. Hyde's tables there are ten females and 
four males. 

The position of the neck of the femur, and the great thickness of the 
muscular coverings, render its fracture from a direct blow a very rare 
circumstance ; indeed, it can only happen as the result of gunshot ac- 
cidents, or other similar penetrating injuries. 

It is broken therefore usually by indirect blows, such as a fall upon 
the bottom of the foot, upon the knee, or upon the trochanter major ; 
or by muscular action alone, as has sometimes happened with very old 
people, who, in walking across the floor, have tripped upon the carpet, 
breaking the bone in the effort to sustain themselves. We must not 
always infer, however, because the patient has tripped, that the bone 
was broken by muscular action ; since it is quite as likely that the fall, 
consequent upon the tripping, has occasioned the fracture; and we ought 
in such cases to make a careful examination of the hip over the tro- 
chanter to ascertain whether it has been bruised, and to interrogate the 
patient as to the manner of the fall. 

Rodet has attempted to show by a series of experiments made upon 
the dead subject, and by other observations, that the direction in which 
the force had acted will determine the situation and direction of the 
fracture. Thus he maintains that when the person has fallen upon the 
foot or knee, the fracture will be intracapsular and oblique ; that if the 
front of the trochanter receives the blow, the fracture will be intra- 
capsular also, but transverse ; if the back of the trochanter is struck, 
the fracture will be partly intra- and partly extracapsular ; and if the 
person falls directly upon the side, or receives the blow fairly upon the 
outer side of the trochanter, the fracture will be entirely without the 
capsule. 1 

Without intending to give my unqualified assent to these proposi- 
tions so ingeniously maintained by Rodet, I am nevertheless prepared 
to admit their general accuracy; and especially has my experience led 
me to believe that falls upon the feet or knees in most cases produce 
intracapsular fractures, and that falls upon the outside of the hip, or 
upon the great trochanter, generally produce extracapsular fractures. 
There are, however, frequent exceptions to this latter proposition. Es- 
pecially have I observed that in persons over fifty years of age, or 
somewhat advanced in life, a fall upon the trochanter has caused an 
intracapsular fracture. The following case, verified by an autopsy, is 
conclusive : 

A man, 75 years of age, was received at Bellevue March 24, 1875. 
He stated that on the same day he had slipped and fallen upon the 
sidewalk, striking with great force upon the trochanter. The house 

1 L'Expe>ience, March 14, 1844. 



372 



FRACTURES OF THE FEMUR. 



Fig. 125. 




Intracapsular fracture, caused by a fall 
upon the trochanter. 



surgeon, Dr. E. A. Lewis, examined the limb immediately on admis- 
sion, and diagnosticated an intracap- 
sular fracture. I saw him during the 
day and confirmed the diagnosis. He 
was feeble, but not suffering much, 
apparently, from shock or from pain. 
Food and stimulants were adminis- 
tered, but no surgical treatment was 
adopted. On the following morning 
he was found to be sinking, and he died 
before night. No complete autopsy was 
obtained, and the cause of his death is 
undetermined. After death Drs. Den- 
nis and Isham repeated the examina- 
tion, and found the evidences of an 
intracapsular fracture very marked, 
including a slight crepitus and rotation 
of the trochanter upon a short axis. 
The accompanying woodcut, taken from 
the specimen now in the possession of 
Dr. Dennis, shows that the fracture was close to the head, and, of 
course, entirely intracapsular. It was not impacted, and no absorption 
of the neck had taken place. 

Pathology. — I have already, when speaking of partial fractures, ex- 
pressed my conviction of the possibility of a partial fracture, or a fis- 
sure of the neck of the femur, and I have referred to the case reported 
by Dr. J. B. S. Jackson, of Boston, as having determined this question 
beyond all possibility of a doubt; yet its occurrence must be regarded 
as an exceedingly rare, and, we may say, improbable event. 

It is much more common to meet with examples of complete fracture 
of the neck both within and without the capsule, unaccompanied with 
a rupture of either the periosteum or the reflected capsule. Such was 
the fact in eight cases examined by Colles; in three of which, however, 
he believed the fracture not to have been complete, but Robert Smith 
thinks they were all of them examples of complete fracture. 1 Stanley 
has also related a case of complete separation of the bone unaccom- 
panied with laceration or injury of either the periosteum or capsular 
ligament. This was in the person of a man aged sixty years, who had 
been knocked down in the street. On being admitted into St. Bar- 
tholomew's Hospital, shortly after the injury, he complained of pain 
in the hip, but there was neither shortening nor eversion of the limb, 
and its several motions could be executed with freedom and power. A 
fracture was not suspected ; but five weeks after this he died of inflam- 
mation of the bowels. The dissection showed a fracture extending 
through the neck, accompanied with a slight bloody effusion, but no 
displacement of the fragments or laceration of the soft parts. 2 



i Colles, Dublin Hosp. Reports, vol. ii, p. 339. 
2 Stanley, Med.-Chir. Trans., vol. xiii. 



NECK, WITHIN -THE CAPSULE. 



373 



Fig. 126. 



In other examples the bone is not only broken, but displaced to such 
an extent that the capsule is completely torn in two. 

But in a large majority of cases both the capsule and the periosteum 
are only partially torn asunder. 

The intracapsular fracture is generally somewhat oblique, and its 
direction is usually from above downwards, and from within outwards. 
Sometimes its direction is such as to include a portion of the head ; oc- 
casionally it is quite transverse. In one example of an old fracture I 
have seen the ends dovetailed upon each other, the fracture having a 
double obliquity, and not admitting of displacement. 

There may occur also a species of impaction, the lower portion of the 
neck entering the cancellous structure of the head, while its upper por- 
tion rides upon the articular surface, a circumstance which is well illus- 
trated by the annexed woodcut (Fig. 126), copied by Mr. Smith from 
a specimen in the Dupuytren Museum at 
Paris; or the impaction may occur without 
any degree of either upward or lateral dis- 
placement. 

Mr. Liston says: "Even in children 
separation of the head of the bone may, on 
good grounds, be supposed occasionally to 
take place;" 1 by which we understand him 
to mean that a separation of the epiphysis 
which completes the head of the femur may 
occur. Mr. South relates a case in a boy 
ten years of age, who had fallen out of a 
first-floor window upon his left hip. The 
limb was slightly turned out, but scarcely 
at all shortened. The thigh could be readily 
moved in any direction without much pain, 
bur on bending; the limb and rotating it 

outwards, a very distinct dummy sensation was frequently felt, ap- 
parently within the joint, as if one articular surface had slipped off 
another. This was regarded by both Mr. South and Mr. Green as an 
example of epiphyseal separation, and he was placed upon a double-in- 
clined plane, but he felt so little inconvenience from it that he several 
times left his bed and walked about. "We have no information as to 
the result or as to the further progress of the case. 2 

A girl, a?t. 18, was brought before Dr. Parker, of New York, at his 
surgical clinic, Nov. 1850, who had been injured by a fall upon a curb- 
stone, when eleven years old. The accident was followed by suppura- 
tion and a fistulous discharge, from which, however, she finally re- 
covered, but with the foot everted, and a shortening of one inch and a 
half. " Flexion and rotation of the joint occasioned no inconvenience." 
Dr. Parker thought this circumstance alone sufficient to distinguish it 
from hip disease in which anchylosis is the termination. 3 




Impacted fracture -within the capsule. 



1 Liston, Element? of Surgery, Phila. ed., 1837, p. 480, 

2 South, Note to Chelius's Surgery, vol. i, p. 619. 

3 Parker, Araer. Med. Gazette, vol. i, p. 342, Nov. 30, 



1850. 



374 FRACTURES OF THE FEMUR. 

At a meeting of the Kappa Lambda Society, held in New York, 
March 25, 1S40, Dr. Post mentioned a case which he had seen in a 
girl sixteen years old, who, in taking a slight step with a child in her 
arms, made a false movement, and feeling something give way, she was 
obliged to lean against a wall. Dr. Post saw her the next day, when 
he found the affected limb one inch shorter than the opposite one, mov- 
able, the toes turned outwards, no swelling, some slight pain at the 
upper part of the thigh. The trochanter major moved with the shaft. 
There was also crepitus. From the age of the patient, and the slight 
amount of violence by which the injury was produced, Dr. Post thought 
a separation of the epiphysis of the head had taken place. The ex- 
tending apparatus was applied, but the limb remains from a quarter to 
half an inch shorter than its fellow. 1 

Aug. 14, 1865, Andrew Leroy, set. 15, in attempting to escape from 
the House of Refuge, fell from the fourth story. On the following 
morning he was admitted into my wards, at Bellevue Hospital. I 
found his right thigh shortened three-quarters of an inch, and slightly 
abducted ; toes everted. Placing him under the influence of chloro- 
form, we detected a dull crepitus in the vicinity of the joint. It was 
unlike the crepitus of broken bone. With fifteen pounds of extension 
we were able to overcome the shortening entirely, and to put the limb 
in position. This was maintained with Buck's apparatus. At the end 
of two weeks, however, it was ascertained to be shortened half an inch. 
Four more pounds were then added. At the close of my term of ser- 
vice I lost sight of the boy, and have not been able therefore to verify 
my diagnosis ; but I believe it to have been a separation of the upper 
epiphysis. 

These four constitute the only examples of this accident which I find 
reported or of which I have any knowledge, and although there may 
be much reason to suppose that the diagnosis was correct in each in- 
stance, I cannot regard any one of them as actually proven ; nor can 
I admit the accident as fairly established, or the diagnostic signs as 
being properly made out, until these important points have received 
the confirmation of at least one dissection. 

Symptoms. — Whether the limb will be shortened or not must depend 
upon whether the fragments are impacted, or have become displaced in 
the direction of the axis of the shaft of the femur. It is well estab- 
lished that in this fracture the broken ends frequently remain in con- 
tact for several hours or days, or until the gradual contraction of the 
muscles or the weight of the body upon the limb occasions a separa- 
tion, and that consequently there is often at first no appreciable or 
actual shortening of the limb. To determine, however, its existence, 
it is not sufficient to lay the patient upon his back, and place the limbs 
beside each other; we ought also to measure carefully with a tape-line 
from the pelvis to the leg or foot, and from various other points, until 
we have placed this question beyond a doubt. 

If shortening occurs, it may vary from one-quarter of an inch to 
two inches, or even more ; but this extreme shortening is not reached 

1 Post, New York Journ. Mod., vol. iii, p. 190, July, 1840. 



NECK, WITHIN THE CAPSULE. 375 

usually, except after the lapse of several weeks or months, when the 
ligaments have gradually given way under the weight of the body in 
walking, or not until the neck has undergone a partial or almost com- 
plete absorption. 

Sir Astley Cooper has stated that a shortening to this degree may 
occur at once ; but Boyer, Earle, and others doubt the accuracy of 
this opinion, and Robert Smith declares that he does not think the 
capsule would admit of such an amount of immediate displacement, 
unless it were extensively torn, an occurrence which he thinks very 
rare indeed. 

With this qualification, the opinion of Mr. Smith does not differ 
from that entertained by Sir Astley, who only admits its possibility as 
a rare event; in a large majority of cases the shortening does not 
exceed one inch. Of the methods of measurement I shall speak here- 
after. 

Crepitus, unlike shortening, is generally absent when the displace- 
ment of the fragments is complete ; but under no circumstances is it 
easily developed. When the fragments remain in apposition, and the 
femur is rotated for the purpose of moving the broken surfaces upon 
each other, the small acetabular fragment, resting in a smooth cup-like 
socket, and holding upon the opposite fragment by clenticulations or 
by the untorn periosteum, or capsule, glides about in obedience to the 
motions of this latter, and no crepitus can be produced. Nor is the 
difficulty rendered less by pressing firmly upon the trochanter, as 
some surgeons have recommended, since, while this pressure tends, 
no doubt, to fasten the upper fragment in the acetabulum, it tends 
much more to fasten the broken ends together, and thus defeats the 
purpose in view. When, on the other hand, the fragments have be- 
come completely separated, it is almost impossible to bring them again 
into contact. The limb may, perhaps, be easily brought down to the 
same length with the other, but it must by no means be inferred that, 
consequently, the broken ends are in apposition. It is almost certain, 
indeed, that in its progress downwards the trochanteric fragment has 
caught upon the acetabular fragment, and pushed its floating and 
broken extremity downwards before it. Under these circumstances, 
the discovery of a crepitus must be accidental, and is scarcely to be 
looked for. Sometimes, however, we may recognize a sound not un- 
like crepitus, but less harsh, produced by the friction of the trochan- 
teric fragment against the rim of the acetabulum or dorsum of the 
ilium. 

One thing w T e ought never to forget, namely, that by extraordinary 
efforts to obtain a crepitus we may lacerate the capsule or produce a 
displacement of the fragments which we never can remedy, and which, 
without such unwarrantable manipulation, might never have occurred. 

E version of the foot is almost uniformly present in some degree, 
taking place immediately or more gradually, in proportion as the 
fragments become displaced, and the external rotators contract. The 
opposite condition, or an inversion of the foot, is occasionally present, 
and sometimes also the foot is neither turned in nor out, but the toes 
point directly forwards. In sixty cases of fracture of the neck seen 



376 FRACTURES OF THE FEMUR. 

by Cloquct the foot was never turned in, and Boyer never met with 
such an example in all of his immense experience; but Langstaff, 
Guthrie, Stanley, and Ouveilhier have each seen one example, and 
Robert Smith has seen two. 1 I have myself seen one. 

The explanation of the fact that the foot is usually everted is not 
difficult. In the case of an intracapsular fracture it is probably due, 
first, to the relative friability of the laminated or cortical structure on 
the posterior aspect of the neck, in consequence of which this portion 
gives way more readily than the cortical structure on the anterior 
aspect ; second, to the natural form and position of the foot and leg, 
which incline them to fall outwards by their own weight; and third, 
to the powerful action of the external rotators, which are so feebly 
antagonized upon the opposite side. 

In the case of an extracapsular impacted fracture, in addition to 
the second and third causes assigned as influencing the position of the 
limb in intracapsular fractures, there are other special causes. The 
cortical lamina on the posterior aspect of the neck, everywhere more 
frail than upon the anterior aspect, becomes greatly weakened as it 
approaches the trochanter by dividing itself into two laminae, one of 
which penetrates towards the centre of the bone, and the other, the 
thinnest of the two, being scarcely thicker than a sheet of paper, form- 
ing the wall of the bone as it becomes continuous with the trochanter. 
This delicate papery wall easily gives way under the application of 
force, while the anterior wall yields only partially, constituting thus a 
sort of hinge upon which the rotation of the thigh is performed. It is 
probable, also, as suggested by M. Robert, that the angle at which the 
external surface of the trochanter unites with the neck increases the 
tendency to fracture and impaction posteriorly. 

An explanation of the fact already stated, that in rare and excep- 
tional cases the limb is inverted or the toes are permitted to point 
directly forwards, has been thought to be more difficult. Dr. Bigelow 
has had an opportunity of examining a specimen taken from an old 
woman in the dissecting-room, and he concludes that the inversion 
was due to the extent of the comminution, which had separated the 
walls of the shaft so as to receive in the interval the whole neck, in- 
stead of the posterior wall only, as commonly occurs. Dr. Robert 
Smith, of Dublin, cites a similar case verified by the autopsy ; and Dr. 
Bigelow remarks that the specimen numbered 248, in the Mutter 
museum, at Philadelphia, presents the same kind of impaction without 
either inversion or e version. 

Fracture of the neck of the femur within the capsule is not usually 
attended with much pain when the patient is at rest, but any attempt 
to move the limb produces intense suffering, and especially when an 
attempt is made to rotate the limb inwards, or to carry it upwards and 
inwards. 

Occasionally, also, during the first few days or hours after the frac- 
ture, a spasmodic action of the muscles compels the patient to cry out 
from the severity of the pain which it produces. At first the sufferer 

1 Robert Smith, op. cit. , p. 2-3. A. Cooper by B. Cooper, op. eit., p. 151, note. 



NECK, WITHIN THE CAPSULE. 



377 



is unable to indicate clearly the seat of this pain, or, perhaps, it is 
diffused and uncertain in its position ; but after a time he is able to 
refer it chiefly to the region of the groin, opposite the neck of the 



Fig. 127. 



Fig. 128. 









Horizontal section of neck of femur. 
(From Bigelovr.) 



Extracapsular fracture, with inversion. 
(From Bigelow.) 



bone, or to near the point of attachment of the psoas magnus and 
iliacus intern us. There is also usually in this region a great degree of 
tenderness and an unusual fulness. 

If now the limb be seized, and extension gradually but firmly ap- 
plied, it will be soon made of the same length with the opposite thigh ; 
but, the moment the extension is discontinued, the shortening and 
e version will recur, accompanied with pain, and perhaps crepitus. 

The trochanter major is less prominent than upon the opposite side, 
and if e version of the limb exists, the trochanter may be felt indis- 
tinctly upwards and backwards from its usual position. The patient 
having been placed under the influence of an anaesthetic, Ave may prose- 
cute the investigation still farther, and by rotating the limb inwards 
and outwards as far as it will admit, we shall notice that the trochanter 
describes the arc of a smaller circle than in the opposite limb, or that 
the length of its radius has been shortened. It ought to be said at 

25 



378 FRACTURES OF THE FEMUR. 

once, however, that this amount of manipulation is often injurious, and 
seldom proper. 

The patient is generally unable to move his limb, or to bear the 
least weight upon it ; but many examples are on record of persons who 
walked some distance after the fracture had taken place, the capsule, 
and perhaps also the periosteum, not being torn, and consequently the 
fragments not being displaced ; or, possibly, it was at first an impacted 
fracture. 

On the 6th of May, 1875, Mrs. R., of Brooklyn, was ascending a 
flight of steps when her limb suddenly gave way under her, in conse- 
quence of an intracapsular fracture. Mrs. E. was 78 years of age, large, 
and rather fat. For several years she had suffered from rheumatism 
of the right leg, which compelled her, in walking, to bear her weight 
chiefly on the left, and it was this limb which gave way. She was 
assisted to her feet, and with the aid of her daughter ascended another 
flight of steps, bearing some weight on the broken leg. On the follow- 
ing day she got out of bed alone, and unaided, walked a few steps 
moving her limb very carefully. On the same day I saw her and 
found her in bed, the limb shortened half an inch and slightly everted. 
The head of the femur moved with the trochanter and without causing 
crepitus or pain. There was very little tenderness about the hip or 
groin ; no swelling and only a heavy, dull aching pain in the limb. 
The age, the manner of the accident and the shortening of the limb 
were the only signs of fracture, but these were sufficient. 

Finally, after having examined the patient as well as we are able to 
do, in the recumbent posture, if any doubt remains, and it is found 
practicable for the patient to be elevated upon his sound foot, this 
should be done. The broken limb can now be examined thoroughly 
on all sides, and a more accurate opinion formed of the amount of 
shortening and eversion. It will be especially noticed that if the 
weight of the body is allowed to rest upon the limb, in most cases it 
produces insupportable pain. 

Dr. Packard, of Philadelphia, informs me that M. Maisonneuve has 
lately suggested and practiced the following method of diagnosis in 
certain doubtful cases. Lay the patient flat on his belly, and then 
bring the suspected thigh into extreme extension backwards. If it is 
not broken, the neck will strike against the posterior lip of the ace- 
tabulum and the progress of the thigh in this direction will be arrested. 
If it is broken, it can be carried backwards much farther. Of this 
method as a means of diagnosis, it seems proper to say that, if the frag- 
ments have slid past each other and the limb is shortened, it is unneces- 
sary ; and if they are still in apposition, it will be pretty certain to 
cause displacement, and thus do irreparable mischief. 

Prognosis. — The question of bony union after a complete fracture of 
the neck of the femur within the capsule has occupied the attention of 
the ablest surgeons and pathologists for a long period; and while great 
differences of opinion have been expressed as to the probability of the 
occurrence, and as to the value of the testimony on the one side or the 
other, very few have ventured to deny its possibility. 

Among these latter are found, however, the distinguished names of 



THE CAPSULE. 379 

Cruveilhier, Colles, Lonsdale, and Bransby Cooper. It has been re- 
peatedly affirmed, also, that Sir Astley Cooper taught the same doc- 
trine, but with how much show of reason, the following paragraphs 
from his own pen will determine: 

" In the examinations which I have made of transverse fractures of 
the cervix femoris, entirely within the capsular ligament, I have only 
met with one in which a bony union had taken place, or which did not 
admit of a motion of one bone upon the other. To deny the possibility 
of this union, and to maintain that no exception to the general rule 
can take place, would be presumptuous, especially when we consider 
the varieties of direction in which a fracture may occur, and the degree 
of violence by which it may have been produced. For example, when 
the fracture is through the head of the bone, with no separation of the 
fractured ends • when the bone is broken without its periosteum being 
torn ; or, when it is broken obliquely, partly within and partly exter- 
nally to the capsular ligament, I believe that bony union may take 
place, although at the same time I arn of opinion that such a favorable 
combination of circumstances is of very rare occurrence. Much trouble 
has been taken to impress the minds of the public with the false idea 
that I have denied the possibility of union of fracture of the neck of 
the thigh-bone, and therefore I beg at once to be understood to con- 
tend for the principle only, that I believe the reason that fractures of 
the neck of the thigh-bone do not unite, is that the ligamentous sheath 
and periosteum of the neck of the bone are torn through, that the bones 
are consequently drawn asunder by the muscles, and that there is a 
want of nourishment of the head of the bone ; but I can readily believe, 
if a fracture should happen without the reflected ligament being torn, 
that as the nutrition would continue, the bone might unite ; but the 
character of the accident would differ ; the nature of the injury could 
scarcely be discerned, and the patient's bone would unite with little 
attention on the part of the surgeon. 

"In proof of the correctness of my opinion, I enumerated in the 
early editions of this work, forty-three specimens of this fracture, in 
different collections in London, which had not united by bone. At the 
present day these might be multiplied, were it necessary. 

" Such has been the accumulated evidence of the want of power of 
the neck of the femur to unite by bone, in my practice of forty years, 
during which period I have seen but two or three cases which militate 
against this opinion, for many of the preparations which have been 
brought for my inspection as specimens of united fractures of this part 
have proved to be nothing more than the result of the changes con- 
comitant with old age ; and in many of them the two thigh-bones of 
the same subject had undergone the same alteration in texture and in 
form/' 1 

The following passages from a communication made by Sir Astley 
to the London Medical Gazette, for the 25th of April, 1834, are equally 
pertinent : 

1 Sir Astley Cooper on Dislocations and Fractures of the Joints, edited by 
Bransby Cooper, Amer. ed., p. 156. 



380 FRACTURES OF THE FEMUR. 

" I find in a report of the Baron Dupuytren's lecture that he attrib- 
utes to me the opinion that fractures of the neck of the thigh-bone, 
within the capsular ligament, not only * never unite, but that it is im- 
possible that they should unite by bone/ 

" It is quite true that, as a general principle, I believe that those 
fractures unite by ligament, and not by bone, as do those of the patella 
and olecranon. But I deny that I have ever stated the impossibility 
of their ossific union ; on the contrary, I have given the reason why 
they may occasionally unite by bone. 

"The following are my words: 'To deny the possibility of their 
union, and to maintain that no exception to this general rule may take 
place, would be presumptuous/ " etc., etc. 

In conclusion, Sir Astley remarks: "I should not have given you 
this trouble, nor should I have taken it myself, but for the respect I 
bear my friend, the Baron Dupuytren ; for although I have already 
submitted myself to be misrepresented by many individuals, yet I 
should be sorry to be misunderstood by so excellent a surgeon and so 
valuable a friend as Le Baron Dupuytren." 1 

Sir Astley, then, so far from denying, frankly admitted the possi- 
bility of bony union when the neck was broken within the capsule, and 
explained the circumstances under which he believed it might occur. 
The true point in dispute was, whether certain cabinet specimens were 
actually examples of complete fractures, wholly within the capsule, 
united by bone. Some of them Sir Astley thought were only examples 
of chronic rheumatic arthritis, or of interstitial and progressive absorp- 
tion. Some were partial rather than complete fractures ; others were 
partly within and partly without the capsule ; and for this he was 
accused of wilful blindness or stupidity, chiefly by those who them- 
selves being owners of these rare pathological treasures, might possibly 
have felt somewhat annoyed at seeing their value thus depreciated, and 
who, no doubt, would be quite as apt to fall into blindness and parti- 
sanship as Sir Astley himself. The truth' is, however, that although 
the claim has been set up and stoutly maintained for more than thirty 
cabinet specimens, in one part of the world or another, a majority of 
these, including several whose claims were urged upon Sir Astley, have 
been at length declared by all parties unsatisfactory, or absolutely fic- 
titious, and only a fraction of the whole number continue to be men- 
tioned by any surgical writer as probable examples. 2 

1 See also Sir Astley's letter to Prof. Cox, written in 1835, and published in the 
Prov. Med. and Surg. Journ for July 12, 1848, New York Journ. Med. for Sept. 
1848, and appendix to Cooper on Dis. and Frac, Amer. ed., 1851, p. 482. 

2 The following European surgeons have claimed to have in their possession, each, 
one example: Langstalf (Med.-Chir. Trans., vol. xiii, 1827); Brulatour (Ibid., 
vol. xiii, 1827) ; Stanley (Ibid., xviii) ; Swan (Swan on Diseases of Nerves, p. 304) ; 
Adams (Todd's Cyclop., p. 813); Jones (Med.-Chir. Trans., vol. xxiv) ; Chorley 
(Amesbury on Frac, p. 125) ; Field (Ibid., p. 128) ; Soemmering (Chelius's Surgery 
by South, vol. i, p. 621); South (Ibid., p. 621). South also mentions another exam- 
ple as being in the museum of St. Bartholomew's Hospital. This is probably Jones's 
case, which Robert Smith says is preserved in this museum, and which has already 
been enumerated. Bryant (Memphis Med. Rec, vol. vi, p. 108, from British Med. 
Journ., March 14); Fawdington (Amer. Journ. Med. Sci., vol. xv, p. 534, from 
London Med. Gaz., Aug. 16, 1834) ; Harris (Ibid., vol. xviii, p. 246, from Dublin 



NECK, WITHIN THE CAPSULE. 381 

Robert Smith reduces the number to seven, but Malgaigne recog- 
nizes only three, namely : Swan's case, admitted by Sir Astley himself; 
Stanley's case, and one specimen in the Dupuytren museum. In 
neither of these cases, he affirms, has the neck lost anything of its form 
or length by absorption, from which we are to infer that he would 
reject as doubtful all such specimens as had undergone these patho- 
logical changes. 

Indeed, I think, we are not left in doubt as to Malgaigne's opinion 
upon this point. Six of the nineteen cases which I have enumerated 
are declared by him to resemble much more rachitic alterations of the 
neck than true fractures; and yet Robert Smith admits three of the 
six as well-established examples ; but as to the precise grounds upon 
which he rejects these cases, he shall speak for himself: "And it is 
sufficient that we consider the beautiful drawings designed by Sir 
Astley Cooper, to illustrate certain varieties of the alterations, to place 
us on our guard against every pretended consolidation which presents 
itself, accompanied with a shortening and deformity of the head and 
neck. When fractures unite by bone, they do not suffer such enormous 
losses of substance which it would become necessary to admit for the 
neck of the femur." 1 . 

A reference to Stanley's case, as reported by Robert Smith, will 
show that, contrary to Malgaigne's statement, this was also shortened 
and deformed, and that, consequently, according to his own rules of 
exclusion, it also must be rejected ; after which only two remain, 
namely Swan's case, admitted by Sir Astley himself, and No. 188 of 
the Dupuytren museum. 

I should do injustice to my own convictions, moreover, w T ere I not 
to refer my readers to the very judicious criticism upon Mr. Swan's 
case made by Dr. Johnson, and published in the New York Journal of 
Medicine, vol. ii, 3d series, p. 295. 

Since writing the above, my friend Dr. Voss, of this city, has placed 
in my hands an elaborate paper on this subject, from the pen of Dr. 
Edward Zeiss, of Dresden, and which has been translated by Dr. R. 
Newman, Prosector to Chair of Surgery, Long Island College Hospital. 
Dr. Zeiss, after rejecting all other European specimens, claims that 
bony union has occurred within the capsule in a specimen now in his 
possession, and also in a specimen which may be found in the patho- 
logical rabinet of the medico-chirurgical academy of Dresden. 2 I 
regret that I am not able to publish these cases at length, as well, also, 
as the able review of their claims sent to*me by Dr. Newman, in which 
Dr. Newman clearly shows that Dr. Zeiss has completely failed to 

Journ., Sept. 1835). Kobert Hamilton says that Prof. Tiianus showed hirn three 
specimens in the museum of the Hospital of St. Peter, at Amsterdam (Ibid., vol. 
xxxi, 470, from Lond. Med. Gaz., Jan. 6, 1843). Malgaigne says there are three 
specimens in the Dupuytren museum which have been described with the same 
interpretation. The whole number claimed by transatlantic surgeons is therefore 
nineteen. 

1 Malgaigne, Traite des Fractures et des Luxations, torn, i, p. 678. 

2 Description of two specimens of intracapsular fracture of the neck of the femur, 
and union by callus, by Dr. Edward Zeiss, Dresden, 1864. 



382 FRACTURES OF THE FEMUR. 

establish the correctness of his opinions. There is no conclusive evi- 
dence that the bones were ever broken, nor, if they were broken, that 
the fractures were entirely within the capsule. 

On this side of the Atlantic, the number of specimens for which the 
honor is claimed is nearly equal to the original number in Europe; 
but they have not yet, all of them, been subjected to the same sifting 
process as their foreign congeners; and it remains to be seen how many 
of them will come successfully out of a similar fifty years' contest. 

Three of the specimens belonged to Reuben D. Mussey, late Pro- 
fessor of Surgery in the Miami Medical College, at Cincinnati, Ohio. 
He has himself furnished a complete history and description of the 
specimens, accompanied with drawings. 1 One may be found in the 
Wistarand Horner Museum at Philadelphia; 2 one belongs to Willard 
Parker of this city; 3 two to the Albany College Museum; 4 two to the 
Harvard Medical College, Boston ; 5 one to the Mutter collection (Speci- 
men B, 71); one to Dr. Pope, of St. Louis. Dr. Sands, of this city, 
has also lately presented a supposed example to the New York Patho- 
logical Society. 6 

In the former editions of this book I have examined the claims of 
several of these specimens very much at length.; but as new specimens 
are every now and then being presented, to our notice, for each of which 
special claims are set up, and inasmuch as no practical results are likely 
to follow upon a further discussion of this point, or upon its definite 
decision, I have concluded to refer those of my readers who feel a par- 
ticular interest in the matter to either one of my earlier editions, and 
to the various monographs to which I have furnished references. 

I have also in my own cabinet a femur of no inconsiderable preten- 
sions, belonging clearly to that class of specimens recognized by Robert 
Smith. Its neck is greatly shortened, and this surgeon would regard 
it, I think, as an impacted intracapsular fracture, but its claim would 
be promptly denied by Malgaigne, on account of the absorption and 
distortion of its neck. Its history is as follows : 

About the year 1833, Mrs. Wakelee, of Clarence, Erie County, New 
York, set. 68, who was then very low with tubercular consumption, 
and so ill as to be scarcely able to walk across the floor, tripped upon 
the carpet and fell, striking upon her left side. She was unable to rise, 
but was laid upon a bed by her son, Dr. Wakelee, a very intelligent 
physician, residing in the same house, who did not suspect a fracture. 
Dr. Bissel saw her on the following clay, and, on rotating the limb out- 
wards, he says that he discovered a crepitus. His examination was 
greatly facilitated by her extreme emaciation. 

Mrs. W. was placed upon a double inclined plane, with apparatus 
for extension, etc., and left in charge of Dr. Wakelee. On the fifth 

1 Amer. Journ. Med. Sci., April, 1857. 

2 H. H. Smith's Surgery, p. 399. 

8 Johnson's paper on Intracapsular Fractures, op. cit. 
* Trans. New York State Med. Soc, 1858. 

5 liigelow on Dislocation, etc., of Hip, 1869, p. 125. 

6 New York Med. Kec, June 1, 1869. 



NECK, WITHIN THE CAPSULE. 



383 



Fig. 129. 



day the splint was removed, and from this time no dressings of any 
kind were applied. The reason for this change of treatment was, that 
she was likely to live but a few days, in 
consequence of the state of her lungs, and 
that such confinement would only hasten 
her death. Contrary, however, to all 
expectations, she gradually convalesced, 
so that after two or three years she could 
walk on crutches, her toes turning out 
and her limb becoming somewhat short- 
ened. Four years after the accident she 
died, and Dr. Bissel obtained from Dr. 
Wakelee the specimen, of which the ac- 
companying drawing is a faithful deline- 
ation. 

Dr. George K. Smith, of the Long 
Island College Hospital, has made a most 
valuable contribution to our knowledge 
of the anatomy and pathology of the hip- 
joint, which will explain in a great meas- 
ure the discrepancies of opinion which at 
present exist among surgeons as to the 
character of certain specimens, and may 
hereafter enable us to decide with more 
accuracy, and may lead to a better agree- 
ment of opinion. 

His observations prove that anatomists have not hitherto correctly 
described the attachment of the capsule ; that the capsule is seldom, if 
ever, attached at the same point in different persons, while it is as 
uniformly found attached at the same point in the opposite femurs of 
the same person. In order, therefore, to determine whether the line 
of fracture in any given specimen was without or within the capsule, 
we must always compare the fractured bone with its congener, and not 
with the femur of another person. 

He has further shown that after a fracture, and the consequent 
absorption of the neck, the normal position of the capsule is almost 
constantly changed; so that its present attachment does not declare 
what were the points of its attachment before the fracture occurred ; 
and finally, that the absorption proceeds unequally and irregularly, 
yet with great rapidity, in the two fragments ; and as the bony union, 
if it ever takes place, probably occurs subsequent to the arrest of the 
absorption, the line of union cannot in itself alone determine whether 
the fracture was near the head or near the trochanters. 1 

It seems to me probable that under certain favorable circumstances 
this union will occur; these favorable circumstances have relation to 




Vertical section of Mrs. Wakelee's 
femur, acetabulum, and capsule. 



] George K. Smith, Insertion of the capsular ligament of the hip-joint, and its 
relation to intracapsular fracture. Medical and Surgical Reporter, Philadelphia, 
1862. 



384 



FRACTURES OF THE FEMUR. 




several conditions, such as age, health, degree of separation of the 
fragments, laceration of the periosteum and capsule, treatment, etc. 

Robert Smith thinks it is not 
fig. 130. likely to occur unless the frag- 

ments are impacted; but Sir Ast- 
ley Cooper, as we have already 
seen, admitted its possibility when- 
ever the reflected capsule and the 
periosteum were not torn, and at 
the same time the fragments were 
not displaced. If to these condi- 
tions we were to add moderate 
but not extreme age, with good 
health, we can see no sufficient 
reason why, under judicious treat- 
ment, bony union might not occa- 
sionally be expected. But such a 
combination of circumstances is 
probably exceedingly rare; and, 
what is more unfortunate, if they 
exist, the fracture is not likely to 
be recognized, and the surgeon 
will fail to avail himself of those 
advantageous coincidences which 
might, if understood and properly 
(From treated, secure a bony union. Du- 
puytren says, when the fragments 
are not displaced "its existence 
may be suspected, but cannot be positively asserted." There will not be 
wanting, however, examples in which surgeons will believe or affirm 
that they have recognized the fracture and wrought the cure. I have 
heard of many such instances, and Mr. Smith has referred to one, 
which is quite pertinent, as having been reported in the Gazette des 
Hopitojux. A woman, set. 64, was treated for an intracapsular frac- 
ture of the neck of the femur at one of the hospitals in Paris, and a at 
the end of four weeks she was discharged perfectly cured, and without 
shortening." We fully partake of Mr. Smith's surprise at the impu- 
dence of this claim, yet we do not see in it much greater improbability 
than in Mr. Swan's case, received by both Mr. Smith and Sir Astley 
himself, where the neck was found almost wholly united by bone in 
five weeks, although the woman was 80 years old, and actually dying 
while the process was going on ! Says Dupuytren, " I would lay it 
down as a general principle that all fractures of the neck of a cylindri- 
cal bone should be kept at rest twice as long as ordinary fractures of 
the same bone; and even after that period I have seen displacement 
take place. The term may, therefore, be lengthened to a hundred 
days, or even longer in aged and feeble persons, whose powers of rep- 
aration are much deteriorated." 

It is not the purpose of the writer to describe particularly all of the 
accidents or pathological conditions with which these fractures may be 



Impacted fracture within the capsule. 
Bigelow.) 



NECK, WITHIN THE CAPSULE. 



385 



Fig. 131. 



confounded. It is sufficient to allude to them, and leave to others the 
labor of a complete historical record ; but I am tempted to devote a 
paragraph to what has been variously termed "morbus coxae senilis" 
(Robert Smith) ; " chronic rheumatic arthritis " (Adams) ; " interstitial 
absorption of the neck of the thigh-bone" (B. Bell) ; " rheumatic gout" 
(Fuller) ; and by others " interstitial and progressive absorption ;" but 
the exact nature and cause of which morbid changes are not yet fully 
understood. Mr. Colles does not think this partakes of the nature of 
rheumatism. I have myself a specimen of what has been more gener- 
ally called chronic rheumatic arthritis, 
occurring in the knee-joint, accompanied 
with a flattening and eburnation of the 
articular surfaces, and Gulliver has shown 
that similar changes of form in the neck 
of the bone may occur in tolerably young 
persons. 

I suspect also that it will be found to 
occur under a greater variety of circum- 
stances, and to present a greater variety 
of forms than have yet been described ; 
and we shall perhaps find a partial ex- 
planation of this diversity and frequency 
in one single circumstance, namely, the 
peculiar anatomical structure of the neck. 
The neck of the femur stands nearly at 
a right angle with the shaft, or at an 
angle so great as that the weight of the 
body, even in health, has the effect to 
gradually depress the head below the top 

of the trochanter major, and to diminish its length. This is seen con- 
stantly in the striking change of form which occurs between childhood 
and old age. Xow, if from any cause whatever, such as a blow upon 
the trochanter or upon the foot, the neck or head is made to suffer, and 
inflammation, or perhaps only a slight degree of increased action in the 
absorbents, ensues, resulting in an equally slight softening of the bony 
tissue, these pathological circumstances may end, sooner or later, in a 
striking change of form in the neck or head. But it is not necessary 
to suppose an external injury to explain the occurrence of this inflam- 
mation, and consequent softening of the bone; a scrofulous, or rickety, 
or tuberculous constitution may occasion it, and we see no reason why 
these conditions are not as likely to lead to a change of form here as in 
the bones of the leg or of the spine. A change of form in the head 
may be the result of an ulceration of the cartilage; and a change of 
form in the neck, of ulceration of the neck. Among other causes, also, 
"chronic rheumatic arthritis" may operate in a large proportion of those 
examples which belong to advanced life. One case, reported by Gul- 
liver, would seem to show that a deformity may occur here as a result 
of disease, and independently of pressure, 1 yet it is plain, from the di- 




Section of a sound adult femur. 



1 Gulliver, Lond. Med.-Chir. Kev., vol. xxxix, p. 544. 



38(5 



FRACTURES OF THE FEMUR. 



rection which the deviation of the head and neck usually takes, that 
pressure perforins an important part in the causation. 

From these various causes, operating in these diverse ways, we shall 
have the different deformities enumerated and described by surgical 
writers. The head flattened, irregularly spread out, depressed and 
polished; the neck shortened and irregularly thickened and expanded; 



Fig. 132. 




Chronic rheumatic arthritis. (Miller.) 



the trochanter major rotated outwards and drawn upwards ; sinuous 
chasms traversing the neck, produced by ulceration; and finally, short- 
ening of the neck, by a true interstitial absorption, and with little or 
no increase in its breadth, the trochanter major also being rotated out- 
wards. It would be strange, moreover, if the interior of these bones 
did not present some changes in structure, such as have been frequently 
observed, namely, an irregular expansion or condensation of the eel-, 
lular tissue, and which latter might easily be supposed, by one who was 
inattentive to all of these circumstances, to indicate the line of an 
imaginary fracture. 

The following example will illustrate the incipient stage of one class 
of these cases, namely, that in which the neck is not only shortened, 
but its surface is irregularly seamed, as if it had been broken and im- 
perfectly united. 

William Clarkson, set. 43, was admitted into the Toronto Hospital, 
C. W., May 5, 1858, with tubercular consumption, of which he died 
on the 25th of the same month. 

He had been under the care of Dr. Scott, and it having been noticed 
that he complained of his right hip at the time of admission, an autopsy 
was made on the 25th, at which I was, through the courtesy of the 
house surgeon, permitted to be present. 



NECK, WITHIN THE CAPSULE. 387 

We examined both hip-joints, and found the neck of the right femur 
shortened, especially in its posterior aspect. At the junction of the 
head with the neck, posteriorly, and extending about half-way around, 
the bone was carious, and so far absorbed as to leave a sulcus of a line 
or two in depth, and of about the same width. Adjacent to this, also, 
the bone was quite soft, yielding under the slightest pressure of the 
knife. There was no other appearance of disease. The opposite femur 
was sound. 

The hospital record furnished the following account of his case, so 
far as the injury to his hip was concerned : 

About nine months before admission, then laboring under the mal- 
ady of which he finally died, he received a blow upon his right tro- 
chanter, ever since which he had been lame, and suffered pain in the 
region of the hip-joint. The pain was felt especially in the groin, 
when the trochanter was pressed upon, or when the sole of his foot 
was percussed. The thigh was slightly flexed ; the toes a little everted; 
and he walked with some halt. 

The case of the soldier, Fox, reported by Gulliver, and who died of 
tuberculosis, presents a case also exactly in point, but illustrating a 
later stage, or the completion of the same process. 

Of the precise nature of the changes in the two following examples 
I cannot be certain, since they have not been determined by dissection. 
They will serve, however, to illustrate the usual history and progress 
of a considerable number of cases. They certainly were not examples 
of fracture. 

Ephraim Brown, when twelve years old, fell from a tree and struck 
upon his right foot. Dr. Silas Holmes, of Stonington, Ct., was called. 
Of the particular symptoms at this time, I have only learned that the 
leg was not shortened. The doctor laid a plaster upon his hip, and 
left him without any further treatment. In three days he was able to 
walk on crutches; in three weeks he walked without crutches, and in 
four months was at work as usual. There was at this time no short- 
ening or deformity of any kind. 

Mr. Brown subsequently enlisted as a soldier in the war of the 
American Revolution, and experienced no difficulty in this hip, until 
after a severe illness which followed upon an unusual exposure, when 
he was about thirty-five years old. At this period the leg began to 
shorten, but the shortening was uaccompanied with pain or soreness. 

He consulted me, July 17, 1845, at which time he was eighty-three 
years old, and a remarkably strong and healthy-looking man. The 
shortening, which had ceased to progress some years before, amounted 
at this time to two and a half inches. 

An officer in the United States army addressed to me the following 
letter, dated November 13, 1849: 

"My mother-in-law, Mrs. S., of D., some three years since fell down 
a flight of stairs, striking on her side upon a stone, injuring the hip- 
joint severely; but, upon examination, her physician declared that 
there was neither a fracture nor a dislocation, and said that she would 
gradually recover. Something like one year since the injured limb 
commenced shortening, so that she can now barely touch her toe to 



388 FRACTURES OF THE FEMUR. 

the floor as she walks. She can bear but little weight upon it, and 
is compelled to use a crutch or a cane constantly. So much time has 
now elapsed, and the limb is so little better, and constantly becoming 
shorter, I have proposed to ask your opinion," etc. 

I need scarcely say that I had no hesitation in pronouncing this a 
case of chronic inflammation of the bone, accompanied with softening 
and gradual change of form, either of the neck or head, or of both. 

It is proper that I should state briefly, before I leave this subject, 
what constitute the chief difficulties in the way of union by bone within 
the capsule. 

The persons to whom the accident occurs are generally advanced in 
life, and consequently the process of repair is feeble and slow. 

The head of the bone receives its supply of blood chiefly through 
the neck and reflected capsule, and when both are severed, the small 
amount furnished by the round ligament is found to be insufficient. 

When the fragments are once displaced, it is difficult, as I have al- 
ready explained, if not impossible, to replace them. 

The direction of the fracture is generally such, that the ends of the 
fragments do not properly support and sustain each other when they 
are in apposition. 

The fracture is at a point where the most powerful muscles in the 
body, acting with great advantage, tend to displace the broken ends. 

Aged persons, who are chiefly the subjects of this accident, do not 
bear well the necessary confinement, and especially as the union requires 
generally a longer time than the union of any other fracture ; so that a 
persistence in the attempt to confine the patient the requisite time often 
causes death. 

Whether the absence of provisional callus as a bond of union, and 
the interposition of synovial fluid between the ends of the fragments, 
constitute additional obstacles, I am not fully prepared to say. In the 
opinion of many surgeons these circumstances constitute very serious, 
if not the chief, obstacles. 

It remains only to consider what is the usual result of this fracture. 

The fragments, more or less displaced, undergo various changes. 
The acetabular fragment is generally rapidly absorbed as far as the 
head ; and occasionally a considerable portion of this latter diappears 
also ; while the trochanteric fragment appears rather as if it had been 
flattened out by pressure and friction, it having gained as much gene- 
rally in thickness as it has lost in length. To this observation, how- 
ever, there will be found many exceptions. Sometimes the trochan- 
teric fragment forms an open, shallow socket, into which the acetabular 
fragment is received ; or its extremity may be irregularly convex and 
concave, to correspond with an exactly opposite condition of the ace- 
tabular fragment. (Fig. 133.) 

Ordinarily the two fragments move upon each other, without the 
intervention of any substance ; but often they become united, more or 
less completely, by fibrous bands (Fig. 134), which bands may be short 
or long, according to the amount of motion which has been maintained 
between the fragments while they are forming, or to the degree of sep- 
aration which exists. 



NECK, WITHIN THE CAPSULE. 



389 



The capsular ligaments are usually considerably thickened, and 
elongated in certain directions, and not unfrequently penetrated by 
spiculse of bone. They are also found sometimes attached by firm 
bands to the acetabular fragment. 

A permanent shortening, and either with or without eversion of the 
limb, are the invariable consequences of this accident. Indeed, not a 



Fig. 133. 



Flu. 134. 





Fracture of cervix fenioris within capsule. 
Ununited. Opposite surfaces irregularly con- 
vex and concave, and polished; moving 
slightly upon each other. (From a specimen 
in the possession of Dr. Josiah Crosby.) 



Mayo's specimen. United by ligament. Patient 
lived nine months after the accident. The tro- 
chanter minor arrested the descent of the head. 
(From Sir A. Cooper.) 



few succumb rapidly to the injury, perishing from a low, irritative 
fever, or from gradual exhaustion, within a month or two from the 
time of its occurrence. .Says Robert Smith : " Our prognosis, in cases 
of fracture of the neck of the femur, must always be unfavorable. In 
many instances the injury soon proves fatal, and in all the functions 
of the limb are forever impaired ; no matter whether the fracture has 
taken place within or external to the capsule — whether it has united 
by ligament or bone — shortening of the limb and lameness are the in- 
evitable results." 

Treatment. — In case, then, of a complete fracture within the capsule, 
existing without laceration of the reflected capsule, or displacement of 
the fragments, and equally in case of a fracture at the same point with 
impaction, the treatment ought to be directed to the retention of the 
bone in place, by suitable mechanical means, for a length of time suffi- 
cient to insure bony union, or for as long a time as the condition of the 
patient will warrant. 

The means which are, in my judgment, best calculated to fulfil this 
important indication, are complete rest in the horizontal posture, the 
limb being secured by the same apparatus which we employ with so 



390 



FRACTURES OF THE FEMUR. 



much success in fractures of the shaft. In fractures of the neck, how- 
ever, whether within or without the capsule, we employ no coaptation 
splints; and the amount of extension ought to be only one-half of that 
generally employed in fractures of the shaft, say about ten pounds. 
The long side-splint, with a foot-board, to prevent eversion of the 
limb, must not be omitted. In my hands, and in the hands of my 
expert house surgeons, the apparatus has undergone so many modifica- 
tions from the original plans of Crosby and Buck, that I shall hereafter 
find it necessary to designate it as my own. 



Fig. 135. 




Author's apparatus for fractures of the neck of the femur. 

Another apparatus, formerly employed by me in fractures of the 
neck of the femur, but for which I have lately substituted my own, is 
Gibson's modification of Hagedorn's, in which the sound limb is first 
secured to the foot-board, and the broken limb is subsequently brought 
down to the same point. By this method, as by my own apparatus, 
we may avoid the necessity of a perineal band, which is so painful, in- 
supportable often when the fracture is at the neck. 

In treating this fracture, supposing no displacement to exist, no ex- 
tension beyond that which is necessary to insure perfect quiet can be 
proper, inasmuch as the fragments are not overlapped ; and they need 
only a moderate assistance to enable them to maintain their present 
position against the action of the muscles. Moreover, if the fragments 
are impacted, violent extension would disengage them, and render their 
displacement and non-union inevitable. 



Fig. 136. 




Gibson's modification of Hagedorn's splint. 



I am prepared to affirm, from my own experience, that more patients 
will endure quietly the position of extension for a length of time than 



NECK, WITHIN THE CAPSULE. 



391 



the flexed position, whether in this latter the patient is placed upon 
his side or upon his back. 

How long the patient will submit to this, or to any other mode of 
securing perfect rest, is very uncertain, and the decision of this question 
must rest with the individual cases and the good sense of the surgeon. 



Fig. 137. 




Gibson's modified splint applied. 



Not very many old and feeble people will bear such confinement many 
days without presenting such palpable signs of failure as to demand 
their complete abandonment. 

Horizontal extension was adopted in Jones's case, and also in the 
case reported by Fawdington, and is said to have been successful. In 
Brulatour's case the limb was kept extended two months ; in Mussey's 
second case Hartshorne's straight splint for extension remained upon 
the limb eighty-four days ; in Bryant's case a long splint was used 
" some weeks." 

It is true, however, that other plans of treatment seem to have been 
equally successful. In the case reported by Adams the limb was 
placed over a double-inclined plane, made of pillows, five weeks ; and 
in Mussey's third example the limb remained in the same position 
three months. Chorley laid his patient upon the sound side, with the 
thighs flexed, for a space of two weeks, and then turned him upon his 
back, still keeping the thighs flexed. At the end of six weeks he was 
placed in a straight position, etc. 

But in a majority of the examples reported, the existence of the 
fracture was either not suspected, or bony union was not anticipated 
or desired, consequently no treatment having in view the confinement 
of the broken bone was adopted. Yet the success, it was claimed, was 
as great as that which has followed either of the other plans. Harris's 
patient was simply laid on a sofa. Field's patient, who broke the neck 
of both femurs within the capsule at different times, was in each case 
left without treatment, except that she lay upon her bed. Mussey him- 
self removed all dressings from Dr. Dalton's patient on the eighteenth 
day, and placed him upon his feet, and Dr. Wakelee removed the 
apparatus from his mother on the fifth day. 

Nor are we without evidence that the careful and judicious applica- 
tion of splints, long continued, and employed under the most favorable 
circumstances, will sometimes fail. The two following cases confirm 
these remarks. The first occurred in the practice of Dr. James R. 
Wood, of this city: "M. J., a young lady, set. 16 years, of vigorous 



392 FRACTURES OF THE FEMUR. 

constitution, perfectly free from any constitutional taint, either of 
scrofula, syphilis, or cancer, was caught between the wheels of two 
carriages, the one stationary, the other in motion. The blow was 
received directly on the trochanter major of the right side. The 
symptoms which presented themselves showed conclusively that there 
was a fracture. There was shortening, loss of voluntary motion, and 
eversion; by placing the finger on the trochanter major, and the thumb 
in the groin, a well-marked crepitus could be felt on extension and 
rotation being made. There was no laceration or other complication 
of the injury. She was placed on Ainesbury's splint, with side splints 
accurately adjusted, and every precaution taken to insure a perfect 
union. The limb was kept on this splint without being disturbed for 
six weeks. At the end of that time it was taken from the splint, and 
examined with care; the signs of fracture still remained. The limb 
was replaced on the splint, and the dressings as before ; everything 
w r as attended to in the general management of the case which the doctor 
thought would be conducive to perfect union. The patient was kept 
for three weeks longer on the splint, which was then removed. It was 
found that there was no union. Patient lived for three years, and was 
so lame that she was ahvays obliged to use a crutch in walking. At 
the expiration of three years she died of an acute disease. 

" On examination of the cervix femoris, it was found that there had 
been a transverse fracture of the bone just at the junction of the head 
and neck. The head of the bone was still attached to the acetabulum 
by the ligamentum teres. The process of absorption had been going 
on, and the head of the bone had already been absorbed below the 
level of the acetabulum, and what remained was soft and spongy, 
easily broken with the handle of the scalpel. The neck of the bone 
was rounded off, and covered with a fibrous deposit. This was not a 
case of diastasis, as has been suggested by an eminent surgeon, who 
judged simply from the age of the patient. She was full sixteen when 
the accident happened, and over nineteen w r hen she died." 

The second was in the person of a man, set. 25 years, who was at the 
time of the accident robust and in good health. "He was dancing at 
his sister's wedding; while cutting a pigeon wing, he struck the foot 
upon which he was resting from under him, and fell, striking directly 
upon the trochanter major. He was unable to rise; a carriage was 
called, and he was taken directly to the New York Hospital. There 
he came under the charge of Dr. J. Kearney Rodgers. A fracture was 
immediately diagnosticated, and for a few days he was kept on the 
double-inclined plane. The straight splint was then used, and the 
dressings kept up for six weeks; at the end of that time they were 
taken off, and the limb examined; there was no union. The limb was 
continued in the straight splints for three weeks longer, and again ex- 
amined ; there was still no union. The patient was again replaced in 
the straight splint for two weeks longer, but no union occurred. At 
the end of three months from his admission he was discharged; he was 
in good health, but so lame that he was obliged to use two crutches in 
walking. After his discharge the patient became very intemperate; 
and in the course of a few weeks he applied for admission to Bellevue 



NECK, WITHOUT THE CAPSULE. 393 

Hospital. He was much debilitated, and had an exhausting diarrhoea. 
Shortly after his admission an immense abscess formed over the joint, 
which discharged profusely. The man died shortly after from exhaus- 
tion, and the specimen came into Dr. Van Buren's hands, the patient 
having been in his service. Dr. Van Buren was aware of the patient's 
previous history, the treatment, etc., at the New York Hospital, and a 
careful examination was made. 

"The capsular ligament was destroyed entirely by the suppurative 
process; there was a formation of callus upon the trochanter major; the 
ligamentum teres was entirely absorbed ; the head of the bone was spongy, 
as if worm-eaten; the direction of the fracture was oblique, commenc- 
ing just at the articulating surface of the head and ending just within 
the capsule ; the upper end of the shaft of the bone showed this same 
appearance that was marked in the head. These points are beautifully 
shown in the specimen at the present time. The opinion of Charles E. 
Isaacs, M.D., the able Demonstrator of Anatomy of the University 
Medical College, is, that this fracture was entirely within the capsule." 1 
The bone may be seen in the museum of the University Medical Col- 
lege, New York. 

Such equal results from opposite plans, and unequal results from 
similar plans of treatment, are not calculated to increase our faith in 
the testimony which most of the foregoing examples are supposed to 
furnish of the possibility of bony union. On the contrary, they cannot 
fail to suggest a doubt as to whether some of them, at least, were not 
i naccurately diagnosticated . 

But admitting that they were not, the testimony which they furnish 
in relation to treatment is too inconclusive to be made available for 
instruction, and we are still at liberty to adopt that which seems most 
rational, without reference to the experience of others. 

The reasons why I would prefer my own plan have already been 
stated in part, to which I will now add, that if an error should occur 
in the diagnosis — if it should prove finally to have been a fracture 
without the capsule — then this treatment would be correct, and no in- 
jury would come to the patient from the error in diagnosis; but if we 
adopt Sir Astley Cooper's suggestion, namely, to get the patient upon 
crutches as soon as possible, perhaps as soon as fourteen days, an error 
in diagnosis might be followed by the most disastrous consequences. 

(b.) Neck of the Femur without the Capsule. 

Causes. — Like fractures within the capsule, these also occur most 
frequently in advanced life. They are not, however, as often met with 
in extreme old age as are fractures within the capsule ; and they are 
much more often met with in persons of middle age, and in younger 
persons, than are intracapsular fractures. Of fractures recognized as 
extracapsular, in Dr. Hyde's tables, ten were under fifty years, and 
seven at or over fifty. The three youngest were respectively thirty, 
twenty-five, and twenty years of age. 

1 Johnson, op. cit., pp. 13-15. 
26 



394 FRACTURES OF THE FEMUR. 

As to the immediate causes, we have already mentioned in the pre- 
ceding section that fractures without the capsule seem to be the result 
generally of falls or of blows received directly upon the trochanter ; 
occasionally, also, they are produced by falls upon the feet or upon the 
knees. 

Pathology. — These fractures may occur at any point external to the 
capsule, but generally the line of fracture is at the base, corresponding 
very nearly with the anterior and posterior intertrochanteric crests. 
Almost invariably the acetabular penetrates the trochanteric fragment 
in such a manner as to split the latter into two or more pieces. The 
direction of the lesions in the outer fragments preserves also a remark- 
able uniformity ; the trochanter major being usually divided from near 
the centre of its summit, obliquely downwards and forwards toward 
its base, and the line of fracture terminating a little short of the tro- 
chanter minor, or penetrating beneath its base ; while one or two lines 
of fracture usually traverse the trochanter major horizontally. 

In an examination of more than twenty specimens, I have noticed 
but two or three exceptions to the general rules above stated. 

In Dr. Mutter's collection, specimen marked B 115 is not accompa- 
nied with either impaction or splitting of the trochanteric fragment; 
but the neck having been broken close to the intertrochanteric lines, 
has, apparently, slid down upon the shaft about one inch, at which 
point it is firmly united by bone. 

Dr. Neill has also a specimen of fracture at the same point, but with- 
out union of any kind, in which no traces remain of a fracture of the 
trochanters. The acetabular fragment has moved up and down upon 
the trochanteric until it has worn for itself a shallow socket three inches 
and a half long; the approximate surfaces being smooth and polished 
like ivory. 

The trochanter major is usually turned backwards, the shaft of the 
femur being rotated in this direction, the same as is usually observed 
in other fractures of the neck of the femur. I have seen one exception 
to this general rule in a specimen belonging to Dr. Mutter (No. 29) ; 
the trochanter in this instance is turned forwards, so that the neck is 
shorter in front than behind. 

The upper fragments of the trochanter major, whenever the lines of 
fracture are transverse, are generally inclined inwards toward the neck, 
as if displaced in this direction by the force of the blow, or perhaps 
by the resistance offered by certain muscles and ligamentous bands 
which find an insertion upon its summit. 

The neck is found, in most cases, standing inwards at nearly a right 
angle with the shaft, the head being much more depressed than the 
outer extremity of the neck ; in consequence of which the lower margin 
of its broken extremity is driven much deeper into the trochanteric 
fragment than is the upper margin. 

Malgaigne believes that impaction, with consequent fracture of the 
trochanters, is never absent in true extracapsular fractures, unless it 
be in that very unusual variety in which the trochanter forms a part 
of the inner fragment (fractures through the trochanter major and base 
of the neck). Robert Smith entertains the same opinion, although 



:nece:, without the capsule. 



395 



Malgaigne does not seem to have so understood him. I cannot agree, 
however, with either of these gentlemen that the rule is so invariable, 
since I am confident that no such splitting has occurred in either of 
the two specimens to which I have referred as belonging respectively 
to Drs. Mutter and Neill. It is true these are both old fractures, and 
to some extent the signs of fracture may have become obliterated, but 



Fig. 139. 



Fig. 140. 




Impacted extracapsular fractures. (R. Smith, and Erichsen.) 



in Mutter's specimen an abundant callus indicates plainly enough 
where the shaft separated from the neck, while the trochanter major 
is smooth as in its normal condition, nor does its summit incline either 
way from its usual position. Neill's specimen, though less satisfactory, 
does not fail to convince me that neither impaction nor splitting of the 
trochanters ever occurred. 

It is certain, however, that impaction and comminution of the outer 
fragment are very constant, and that, whether the fracture is produced 
by a fall upon the feet or upon the trochanter major. But the impac- 
tion does not necessarily continue; sometimes, indeed, it does, and the 
position of the limb, whatever it may be at the moment, remains un- 
alterably fixed ; either very little or considerably shortened, according 
to the degree of impaction ; rotated outwards or inwards, or in neither 
direction, perhaps, according to the direction of the force and the 
amount of comminution. In other cases, owing to the extreme com- 
minution, and to the w T ide separation of the trochanteric fragments, or 
to the contraction of the muscles inserted into the top of the femur, or 
to the weight of the body in attempts to walk, or to injudicious hand- 
ling on the part of the surgeon, such as forcible rotation, by which the 
neck is made to act as a lever, and to actually pry the fragments apart, 
or to violent extension, by which the impaction is overcome — owing to 
some one or several of these causes it often happens that the fragments 
separate, and the leg becomes immediately more shortened, movable, 
and more inclined to rotate outwards. 



396 FRACTURES OF THE FEMUR. 

Symptoms. — The symptoms which indicate a fracture of the neck of 
the femur without the capsule, are pain, mobility, crepitus, shortening 
and eversion of the limb. The trochanter major is not as prominent 
as upon the opposite side ; and, especially where the fragments are not 
impacted, but are completely separated, it rotates upon a shorter axis. 
There are also several other signs to which I shall refer when consider- 
ing the differential diagnosis. 

Before considering more in detail the value of these several signs, I 
wish to call attention to a fact which has been often observed by myself 
and others, namely, that the patient is able, sometimes, immediately 
after this accident, to take a few steps; yet never, perhaps, without 
considerable pain. The same may happen in an intracapsular im- 
pacted fracture, but it happens much more often in the extracapsular 
impacted fracture ; but the following case is the most remarkable, in 
this point of view, of any which has come under my notice : A labor- 
ing man, about 50 years of age, presented himself at myelinic at Belle- 
vue Hospital, some time during the fall of 1874, who stated that two 
years before he had fallen a distance of nine feet, striking upon his 
side ; that after a little he arose and, with the aid of a stick, walked a 
mile or more to his home. Walking caused great pain in his hip, and 
he was much exhausted when he reached home, and went to bed ; but 
having no suspicion that his limb was broken he did not call a surgeon. 
Within a fortnight from this time he began to walk about, and a week 
later he began to perform ordinary labor, yet not without pain. 

When this man came before the class I found the limb shortened 
three-quarters of an inch, the toes everted, the trochanter major de- 
pressed — that is, flattened — irregular in form, and much increased in 
breadth. He is a man of intelligence, and is certain that these changes 
of form, etc., were observed by him very soon after his recovery. It 
seems proper, therefore, to assume that this was not an example of 
gradual change of form and position due to a chronic ostitis, but that 
it was an extracapsular fracture. 1 

The pain and tenderness, accompanied sometimes with swelling and 
discoloration, are situated most often in front of the neck of the bone. 

Mobility exists in a majority of cases, even when the fragments are 
impacted ; that is,, the limb can be moved pretty easily in any direction 
by the surgeon, but not without producing pain or provoking muscular 
spasms, yet the patient himself is unable to move the limb by his own 
volition, or he can only move it slightly. 

Crepitus is present whenever there exists a moderate but not com- 
plete impaction. It is also present generally when, the trochanteric 
fragment having been extensively comminuted and loosened, the im- 
paction becomes excessive ; and it is only absent when the impaction 
is such that the fragments are completely and firmly locked into each 
other. 

A shortening is inevitable, at least in all cases accompanied with 
either temporary or permanent impaction, and we have seen that one 

1 Canton on Interstitial Absorption of the Neck of the Femur from Bruise, etc. 
London Med. Gazette, Aug. 11, 1848. 



KECK, WITHOUT THE CAPSULE. 



397 



Fig. 141. 



of these conditions seldom fails. According to Sir Astley Cooper the 
shortening varies from half an inch to three-quarters of an inch, but 
Robert Smith has established the following distinction. When the 
fracture is extracapsular and impacted, that is, when it remains im- 
pacted, the shortening is only moderate, varying from one-quarter of 
an inch to one inch and a half; in fourteen cases measured by him the 
average was a fraction over three-quarters of an inch ; but when it 
does not remain impacted it ranges from one inch to two inches and a 
half; indeed, Mr. Smith mentions one example in which the shorten- 
ing reached four inches, and forty-two cases gave an average shorten- 
ing of something more than one inch and a quarter, 

Eversion of the toes is very constant ; but in a few instances upon 
record the toes have been found turned in, or even directed forwards. 
During the winters of 1864 and 1865, 1 found 
a case of this kind in my wards at Bellevue 
Hospital. In the specimen referred to as being 
found in Dr. Mutter's collection, with an in- 
ward or forward rotation of the trochanter 
major, the same relative position of the whole 
limb must have existed ; and in my remarks 
on fractures of the neck w T ithin the capsule, I 
have referred to several examples, some of 
which were probably extracapsular. 

The trochanter major usually seems de- 
pressed or driven in ; and when the two main 
fragments are completely separated, if the 
limb is rotated, the trochanter will be found 
to turn almost upon its own axis, or upon a 
very short radius. 

In enumerating the signs of extracapsular 
fracture, it will be seen that I have, with only 
slight variations, repeated the signs of a frac- 
ture within the capsule. It will become nec- 
essary, therefore, to indicate, as far as possi- 
ble, a differential diagnosis. And without 
pretending that all of the differential signs 
which I shall enumerate are thoroughly estab- 
lished, or that in every case, even after a careful grouping of all the 
symptoms, a satisfactory diagnosis can be made out, I shall state briefly 
my own conclusions, or rather what seem to me to be the probable facts. 




Fracture of the neck of the femur. 
(Fergusson.) 



Signs of a fracture within the 

CAPSULE. 



Produced often by slight violence. 
A fall upon the foot or knee, or a 
upon the carpet, etc. 

Generally over fifty years of age. 
More frequent in females. 



trip 



Pain, tenderness, and swelling less and 
deeper. 



Signs of a fracture without the 

CAPSULE. 

Produced usually by greater violence. 
A fall upon the trochanter major. 

Often under fifty years of age. 

Relative frequency in males or females 
not established. 

Pain, swelling, and tenderness greater 
and more superficial. It is especially 
painful to press upon and around the 
trochanter. 



398 



FRACTURES OF THE FEMUR. 



Signs of a fracture within the 
capsule [continued). 

(The two following measurements to 
be made from the anterior superior spin- 
ous process of the ilium to the lower ex- 
tremity of the malleolus externus or in- 
ternus.) 

Shortening at first less than in extra- 
capsular fractures, often not any. 

Shortening after a few days or weeks 
greater than in extracapsular fractures. 
Sometimes this takes place suddenly, as 
when the limb is moved, or the patient 
steps upon it. 

Measuring from the top of the tro- 
chanter to the condyles or to the malleoli, 
the femur is not shortened. 

Trochanter major moves upon a rela- 
tively longer radius. 

If the patient recovers the use of the 
limb, not restored under three or four 
months. 

No enlargement or apparent expansion 
of the trochanter major, after recovery, 
from deposit of bony callus. 

Progressive wasting of the limb for 
many months after recovery. 

Excessive halting, accompanied with a 
peculiar motion of the pelvis, such as is 
exhibited in persons who walk with an 
artificial limb. 



Signs of a fracture without the 

capsule [continued). 



Shortening at first greater, almost al- 
ways some. 

Shortening after a few days or weeks 
less than in intracapsular fractures. That 
is, the amount of shortening changes but 
little, if at all ; if the impaction continues, 
not at all ; if it does not continue, it may 
shorten more. 

Measuring from the top of the tro- 
chanter to the condyles or to the malleoli, 
the femur may be found a little short- 
ened. 

Trochanter major moves upon a rela- 
tively shorter radius. 

If the patient recovers the use of the 
limb, restored in six or eight weeks. 

Enlargement or irregular expansion of 
trochanter, which may be felt sometimes 
distinctly through the skin and muscles. 

The limb preserving its natural strength 
and size. 

Slight halt, motions of hip natural. 



Prognosis. — In attempting to establish the differential diagnosis, we 
have necessarily been led to consider most of the essential points of 
prognosis. Very little, therefore remains to be said upon this subject. 

Union occurs as rapidly in this fracture as in fractures of the shaft ; 
and perhaps in general more promptly, owing to the existence of im- 
paction. 

But whether it occurs promptly or slowly, or, indeed, if it does not 
occur at all, a remarkable deposit of ossific matter almost invariably 
takes place along the intertrochanteric lines, where the bone has sepa- 
rated from the shaft, and also, not unfrequently, along the lines of the 
other fractures of the trochanter. 

This deposit is no less remarkable for its abundance than for its 
irregularity, long spines of bone often rising up toward the pelvis and 
forming a kind of nobby or spiculated crown, within which the acetab- 
ular fragment reposes. In a few instances these osteophytes have 
reached even to the bones of the pelvis, and formed powerful abut- 
ments, which seemed to prevent any farther displacement of the limb 
in this direction, and by some writers they have been supposed thus 
to fulfil a positive design. A sufficient explanation of their existence, 
however, we think, can be found in the fact that they proceed entirely 
from the trochanteric fragments, whose extensive comminution and 
great vascularity would naturally lead to such results. The same, but 
in a less degree, has already been noticed as occurring in impacted 



NECK, WITHOUT THE CAPSULE. 



399 



fractures at the anatomical neck of the humerus, where certainly such 
bony abutments could not serve any useful purpose. 



Fig. 142. 



Fig. 143. 





Extracapsular fracture. (Erichsen.) 



Extracapsular fracture. (R. Smith.) 



Probably in all, certainly in nearly all cases, the limb will be found, 
after the union is consummated, more or less shortened, generally be- 
tween half an inch and an inch. If exceptions ever occur it must be 
in those examples in which there is no impaction, and it is certain that 
such examples are very rare. Such is the united testimony of all sur- 
geons whose opinions have ever been respected as authority ; and the 
same is true of intracapsular fractures. What ignorance of the ele- 
mentary facts of surgical science do these men exhibit then, who affirm 
that they are able to treat all fractures of the femur without shortening. 

Eversion of the foot is not so constant as shortening, but it will be 
found to exist in some degree in a large majority of cases, even when 
the case has been managed in the most skilful manner ; yet in this re- 
gard something will depend upon the position in which the limb is 
maintained during the treatment. 

Treatment. — The same principles of treatment are applicable here as 
in fractures of the neck within the capsule; by which I mean to say 
that, as in all of those examples of fracture w T ithin the capsule where 
the relation of the fragments is such as to warrant a hope that a bony 
union may be consummated, namely, where the fragments are not dis- 
placed or are impacted, the straight position, with only moderate ex- 
tension, constitutes the most rational mode of treatment; so also in this 
fracture, whenever the fragments are impacted and remain impacted, 
the straight position, with moderate extension, employed only as a 
means of retention, but not so as to overcome impaction, is the most 
suitable. It is only by employing this plan of treatment, which no one 
has yet shown to be inapplicable to either of these two varieties of ac- 



400 



FRACTURES OF THE FEMUR. 



Fig. 144. 




Extracapsular fracture. 



cidents — I do not speak of the opinions which men may have enter- 
tained, but of the practical testimony — it is only, I say, by employing 

this uniform plan of treatment in both 
cases, that those serious misfortunes to the 
patient can be avoided which would neces- 
sarily continue to occur if Sir Astley 
Cooper's advice were followed, namely, to 
allow the patient in the one case to dis- 
pense with splints wholly, and to get upon 
his crutches as soon as the condition of his 
limb and of his body will permit, when it 
is certain that in the other case some re- 
tentive apparatus is generally necessary. 
This conclusion is based upon the admitted 
difficulty of diagnosis. If, as is well un- 
derstood, the diagnosis between these two 
varieties of fracture is often impossible 
during the life of the patient, then how 
■shall we know in any given case which of the two plans to adopt ? If 
we act upon the supposition that it is within the capsule, adopting 
Sir Astley Cooper's method, and it proves to have been a fracture 
without the capsule, we may do irreparable injury to our patient. It 
is precisely here that this distinguished surgeon committed his great 
error; not in denying that certain specimens were fractures of the 
neck of the femur within the capsule united by bone, nor in constantly 
urging upon his contemporaries the improbability of such an event, 
but in that, while he admitted its possibility, he chose to recommend 
a plan of treatment which was unlikely to insure such a union, and 
which, in the uncertainty if not impossibility of diagnosis, was liable, 
upon his supposed authority, to be adopted in many cases of extra- 
capsular fractures. 

Again, if the fracture be extracapsular and not impacted, or the 
impaction has been, for any cause, overcome ; or, if the fracture be 
intracapsular and not impacted, or if the capsule is lacerated and the 
fragments are in consequence displaced; then again no injury need 
result from the treatment, if we adopt the straight position with mod- 
erate extension, such as may be obtained from the use of my own ap- 
paratus, Gibson's, Miller's, or Desault's. That it is, or is not impacted 
we may know generally, by the amount of displacement, although 
we may not easily decide whether the fracture is within or without the 
capsule. Now, the amount of shortening will determine properly 
enough the amount of extension to be employed. In either case, how- 
ever, we shall not employ as much extension as in fractures of the 
shaft; and while in the one case we may only gain a shorter and firmer 
ligamentous union, in the other we shall insure a better and more 
speedy bony union. 

If any surgeon, acting upon the suggestions here made, shall confine 
a feeble or an aged person in the horizontal posture, with or without a 
straight splint, until the powers of nature have become exhausted, and 
death ensues, as our readers have already been admonished may happen, 



THROUGH THE TROCHANTER MAJOR. 



401 



we are not to be held responsible for his want of judgment or of skill. 
We have advised this plan of treatment only for so long a period as 
the condition of the patient renders it entirely safe. No doubt, then, 
in a large number of cases it will have to be abandoned very early, and 
in not an inconsiderable proportion all constraint will be plainly inad- 



FlG. 145. 




Miller's splint for extracapsular fractures. (From Miller.) 

missible/7-om the beginning; and it is for such examples that the treat- 
ment recommended by Sir Astley Cooper for all intracapsular fractures 
ought to be reserved. 

(c.) Fractures of the Neck partly within and partly without the Capsule. 

It is scarcely necessary to say that the line of fracture through the 
neck of the femur may be such, that it shall be in part within and in 
part without the capsule; and such fractures will be even more difficult 
to diagnosticate than either of those forms of which we have just 
spoken. The symptoms will be mainly, however, those which charac- 
terize fractures within the capsule, while the treatment ought to be 
such as we would adopt in those fractures which are wholly without 
the capsule. The chances for bony union are increased in proportion 
as the line of separation extends outside of the capsule, and we ought 
to be diligent in our efforts, if we have made ourselves certain that the 
fracture is partly extracapsular, to secure a good bony union ; a result 
which experience has shown may be reasonably anticipated. 

The necessity for some extension, and of firm retentive apparatus in 
this form of fracture, furnishes another argument in favor of the em- 
ployment of the same means in fractures wholly w T ithin the capsule. 
We shall thus avoid the mischief which might arise from mistaking a 
fracture of the character of w 7 hich we are now speaking, for a fracture 
wholly within the capsule. 



I 2. Fracture through the Trochanter Major and Base of the Neck of 

the Femur. 

This fracture, which Sir Astley Cooper calls a fracture of the " femur 
through the trochanter major/' 1 passes obliquely upwards and outwards 

1 Sir Astley Cooper, op. cit., p. 183. 



402 FRACTURES OF THE FEMUR. 

from the lower portion of the neck, but instead of traversing the neck 
completely, it penetrates the base of the trochanter major; the line of 
fracture being such as to separate the femur into two fragments, one 
of which is composed of the head, neck, and trochanter major, and the 
other of the shaft with the remaining portions of the femur. 

The following two examples are all in relation to which we possess 
any positive information, or in which the diagnosis has been confirmed 
by an autopsy. The first is thus related by Sir Astley Cooper. 

"The first case of this kind I ever saw was in St. Thomas's Hos- 
pital, about the year 1786. It was supposed to be a fracture of the 
neck of the thigh-bone within the capsule, and the limb was extended 
over a pillow rolled under the knee, with splints on each side of the 
limb, by Mr. Cline's direction. An ossific union succeeded, with 
scarcely any deformity, excepting that the foot was somewhat everted 
and the man walked extremely well. When he was to be discharged 
from the hospital, a fever attacked him, of which he died ; and upon 
dissection, the fracture was found through the trochanter major, and 
the bone was united with very little deformity, so that his limb would 
have been equally useful as before." 1 

The second example is reported by Mr. Stanley. 

"A woman, in her sixtieth year, fell in the street and injured her 
right hip. On examination, the limb was found slightly everted, and 
shortened to the extent of three-quarters of an inch, but movable in 
every direction. The extremity of the shaft of the femur was in its 
natural situation ; but behind the femur, and at a little distance from 
it, a bony prominence was discovered, resting upon the ilium, toward 
the great sciatic notch, strongly resembling the head of the femur. 
Various opinions were entertained as to the nature of the injury, some 
believing it to be dislocation, and others a fracture. After a confine- 
ment of several months to her bed, the woman was sufficiently recov- 
ered to walk w T ith the assistance of a crutch, and in this state she con- 
tinued till her death, which took place about three years after the ac- 
cident, during the whole of which period I had watched the progress 
of the case. Having obtained permission to examine the seat of the 
injury, I ascertained that there had been a fracture extending obliquely 
through the trochanter major, and through the basis of the neck into 
the shaft of the femur, and that the prominence which had been mis- 
taken for the head of the bone was occasioned by the posterior and 
larger portion of the trochanter drawn backwards toward the ischiatic 
notch." 2 

Sir Astley relates three other examples in which he believes the 
fractures to have been of the character above described; and he details 
the peculiar plans of treatment which, in each case, he saw fit to recom- 
mend. I can see no reason, however, why the treatment need differ 
from that which has already been recommended for fractures of the 
neck, since the indications are nearly identical in all of these cases ; 
namely, moderate extension, and steady support of the limb in its 
natural position. 

1 Op. cit., p. 184. 2 Stanley, Med.-Chir. Trans., vol. xiii. 




EPIPHYSIS OF THE TROCHANTER MAJOR. 403 



§ 3. Fracture of the Epiphysis of the Trochanter Major. 

So far as I know, the only well-authenticated example of this acci- 
dent is the one reported by Mr. Key to Sir Astley Cooper. 1 The sub- 
ject of this case was a girl, aged about sixteen years, who fell, March 
15, 1822, upon the sidewalk, and struck her trochanter violently 
against the curbstone. She arose, and, without much pain or difficulty, 
walked home. On the 20th she was received into Guy's Hospital, and 
the limb was examined by Mr. Key. The right 
leg, which was the one injured, was considerably 
everted, and appeared to be about half an inch 
longer than the sound limb. It could be moved 
in all directions, but abduction gave her consider- 
able pain. She had perfect command over all the 
muscles, except the rotators inwards. No crepi- 
tus could be detected. Four days after admission 
she died, having succumbed to the irritative fever 
which followed the injury. 

The autopsy disclosed a fracture through the Mr - Aston ^ e ?' s case - 
base of the trochanter major, but without lacera- FromBrvant UySMUSeUm 
tion of the tendinous expansions which cover the 
outside of this process, so that no displacement of the epiphysis had 
occurred, nor could it be moved, except to a small extent upwards and 
downwards. A considerable collection of pus was found, also, below 
and in front of the trochanter. 

The absence of displacement in the fragment, with its peculiar and 
limited motion, sufficiently explained why the fracture could not be 
detected during life. 

In the eighth volume of the Transactions of the Medical and Physical 
Society of Calcutta (1825), J. Clarke, Esq., reports a case of comminuted 
fracture of the trochanter major, which has been mentioned by Mal- 
gaigne as an example of simple fracture of the trochanter ; but, after 
reading the case carefully, I cannot avoid the conclusion that it was 
an example of fracture of the neck without the capsule, accompanied 
with impaction and extensive comminution. " Extravasation," says 
Mr. Clarke, "was discovered within the capsular ligament and around 
the trochanter major; and, on clearing away the muscles, the trochan- 
ter was found crushed and shattered, several pieces entirely detached, 
and fissures extending deeply into the shaft of the bone." 2 

I shall venture to express the same opinion in relation to the case 
reported by Bransby Cooper. 3 The diagnosis was not confirmed by 
an autopsy, and the testimony drawn from Mr. Cooper's account of 
the case is far from being, to my mind, conclusive. It may, indeed, 
have been a simple fracture of the epiphysis ; but there is nothing in 
the narrative to render it improbable that there existed also an impacted 
extracapsular fracture of the neck. 

1 Sir Astley Cooper on Dislocations and Fractures, etc., Anier. ed., 1851, p. 192. 

2 Clarke, Amer. Journ. AJ»>d. Sci., Nov. 1836, vol. ix, p. 181. 

3 B. Cooper, A. Cooper on Dislocations, etc., op. cit , p. 192. 



404 FRACTURES OF THE FEMUR. 

Mr. Poland reports a case, also, which occurred in a boy twelve 
years old, at Guy's Hospital, and which was seen by Mr. Bryant; but 
this was not confirmed by an autopsy. 1 

I have also myself reported one example of this fracture as having 
come under my own observation, 2 but of which I wish now to speak 
somewhat less confidently. The patient, James Redwick, a travelling 
showman, set. 23, fell, in August, 1848, from a high wagon, striking 
upon his left hip. When he got upon his feet, he found himself un- 
able to walk, and was carried to his room. Dr. Wilcox, of Buffalo, 
was called to see him, and applied a long straight splint. Fourteen 
days after the accident I saw the patient with Dr. Wilcox. The thigh 
was not appreciably shortened, nor was there either eversion or inver- 
sion ; but the epiphysis of the trochanter major was carried upwards 
toward the crest of the ilium half an inch, and slightly sent in. No 
crepitus could be detected. The splint was continued five weeks; and 
about a month after, I found the fragment in the same place, but he 
was able to walk with only a slight halt. 

I think this also may have been an extracapsular impacted fracture. 

Fig. 147. 



Sir Astley Cooper's mode of treating fractures of the trochanter major. (From A. Cooper.) 

With the small amount of positive information which we possess in 
relation to this fracture, we might venture a few conjectures as to what 
would constitute its symptoms, or as to the probable results and the 
most suitable treatment; but we prefer to occupy ourselves with a 
simple statement of the facts, so far as they are known, leaving all 
mere speculative inferences to those who choose to make them. 

g 4. Fractures of the Shaft of the Femur. 

Etiology. — Unless the fracture has taken place just above the con- 
dyles, or immediately below the trochanter minor, in a very large pro- 
portion of cases it has been produced by a direct blow, such as the 
passage of a loaded vehicle across the thigh, or the fall of a piece of 
timber directly upon it. An analysis of twenty-one cases, taken in- 
discriminately, presents three fractures immediately above the condyles, 
and these were all produced by falls upon the feet; but of the remain- 

1 Poland, Bryants Surgery, 1st ed., p. 950. 

2 Hamilton, Trans. Anier. Med. Assoc, op. cit., vol. x, p. 254. 



FRACTURES OF THE SHAFT OF THE FEMUR. 405 

ing eighteen, all of which occurred higher in the limb, only two were 
the result of falls upon the feet or of indirect blows, and one of these 
was a fracture just below the trochanter minor. 

Pathology, — It has already been remarked that this bone is most 
frequently broken in its middle third, and usually at a point somewhat 
above the middle of the shaft. I have made the same observation in 
an examination of specimens belonging to Dr. Mutter. In his cabinet, 
of twenty-four fractures of the shaft, three belonged to the upper third, 
two to the lower, and nineteen to the middle third. 

In the adult these fractures are, with only an exceedingly rare ex- 
ception, oblique; and the obliquity is generally greater than in the 
case of other bones. This fact, which it is very difficult to determine, 
in most cases, upon the living subject, I have established by a consid- 
erable number of observations made upon cabinet specimens. A trans- 
verse fracture is found only twice in Dr. Mussey's collection, containing 
thirty examples of fracture of the shaft; and in Dr. Mutter's collection, 
specimen B 71 is an adult femur, broken nearly transversely through 
its middle third; and it is united with a shortening of about one inch. 
Indeed, it is more common to find a transverse fracture in the middle 
third than at any other point of the bone ; but in the upper third the 
obliquity is extreme and almost constant. 

At whatever point of the shaft the bone is broken, the degree of 
obliquity is generally such that the fragments cannot support each 
other when placed in apposition ; unless indeed the fracture is near 
the condyles, where the greater breadth of the bone creates an addi- 
tional support ; but even here the cabinet specimens still present a 
striking obliquity, with more or less overlapping. I believe that in 
each of the three specimens of fracture at this point found in the col- 
lection belonging to the Albany Medical College, the obliquity is such 
that the fragments were not supported, and an overlapping has taken 
place. In specimen 719 the fracture extends into the joint; and al- 
though it is united by bone, a shortening of about one inch has occurred. 

In the case of children, and especially of infants, the rule is reversed; 
the bone is either broken transversely or nearly transversely, or it is 
serrated or denticulated, so that complete lateral displacement is much 
less frequent. 

The same remark is probably true of some fractures occurring in 
extreme old age ; but as the shaft of the femur is not often broken in 
very old persons, owing to the readiness with which the neck yields to 
violence, I have not had an opportunity to verify this opinion. 

The direction of the obliquity varies exceedingly, especially in the 
middle and upper thirds ; in the middle third, however, it is generally 
downwards and inwards ; but in the lower third its direction is, with 
only rare exceptions, downwards and forwards, and the superior frag- 
ment is found lying in front of the inferior. 

In one instance I have found both femurs broken at the same point 
and in the same manner. Mr. L. Brittin, aged about fifty-five years, 
while employed upon a building, fell from a fourth-story window upon 
the stone pavement below, striking upon his feet. In addition to 
several other fractures, I found both femurs broken obliquely down- 



406 



FRACTURES OF THE FEMUR. 



Fig. 148. 




Fracture at base of condyles. 



wards and forwards, just above the condyles. Very little inflamma- 
tion ensued, and although it was found impossible to employ extension, 

union occurred readily, and with only a 
moderate overlapping. In the left limb, 
however, the upper fragment pressed down 
sufficiently to interfere somewhat with the 
patella, and the patient was unable, after 
several months, to straighten the knee com- 
pletely. The motions of the right knee were 
unimpaired. 

I have only once met with a fracture at 
this point in which the line of separation was 
downwards and backwards. As the case 
presents several points of interest, it will be 
proper to narrate the facts somewhat at 
length. 

George Taylor Aiken, of Lockport, N. Y., 
set. 7. May 18, 1854, in jumping down a 
bank of about three feet in height, he broke 
the right thigh obliquely, just above the knee- 
joint. Direction of the fracture obliquely 
downwards and backwards. 
Dr. G., an accomplished surgeon, residing in Lockport, was called. 
The limb was not then much swollen. He applied side splints, rollers, 
etc., carefully, and then laid the limb over a double-inclined plane. 
The knee was elevated about six or eight inches. Before applying the 
splints, suitable extension had been made, and after completing the 
dressings, the two limbs seemed to be of the same length. 

On the second or third day, Dr. G. noticed that the toes looked un- 
naturally white, and were cold. 

Counsel was now called at the request of Dr. G., when it was de- 
termined to abandon all dressings, and direct their efforts solely to 
saving the limb. 

The result was that slowly a considerable portion of his foot died 
and sloughed away, leaving only the tarsal bones. The fracture united, 
but with considerable overlapping and deformity. 

Feb. 26, 1856, the boy was brought to me by his father. On ex- 
amining the fracture, I noticed that the anterior line of the femur 
seemed nearly straight, and this appearance was owing in some degree 
to the muscles which covered and concealed the bone, and in some de- 
gree, also, to the manner in which the fragments rested upon each 
other ; the pointed superior end of the lower fragment resting snugly 
upon the front of the upper fragment, so that no abrupt angle existed 
in front. On the back of the limb, however, the lower end of the 
upper fragment, quite sharp, projected freely downwards and back- 
wards into the popliteal space, so that its extreme point was only about 
half an inch above the line of the articulation. The limb had short- 
ened one inch, and this enabled us to determine accurately that the 
lower point or the commencement of the fracture was one inch and a 



FRACTURES OF THE SHAFT OF THE FEMUR. 407 

half above the articulation, while the point where the line of fracture 
terminated in front was probably quite three inches and a half above 
the joint. 

The motions of the knee-joint were pretty free. The leg was ex- 
tremely wasted, and the anterior half of the foot having sloughed off, 
the sores had now completely healed over. He was able to walk toler- 
ably well without either crutch or cane. 

Subsequently, Dr. G. found it necessary to sue the father of the 
child for the amount of his services, when Mr. Aiken put in a plea of 
malpractice, and that consequently the services were without value. 

The case was tried in the March term of the Niagara circuit of 1856, 
at Lockport, N. Y., the Hon. Benjamin F. Greene presiding. 

On the part of the defence, it was claimed that the death of the foot 
was in consequence of the bandages being too tight. They failed, 
however, to show that they were extraordinarily or unduly tight. 
While on the part of Dr. G., the prosecutor, it was shown that the 
death of the toes was preceded by a total loss of color, and that it was 
not accompanied with either venous or arterial congestion. The medi- 
cal gentlemen examined as witnesses declared that this circumstance 
furnished the most positive evidence which could be desired that the 
death of the toes was not due to the tightness of the bandages, but that 
its cause must be looked for in an arrest of the arterial or nervous cur- 
rents supplying the limb, or in both. They believed, also, that the 
projection of the superior fragment into the popliteal space was suffi- 
cient to cause this arrest. They also believed that overlapping and 
consequent projection could not have been prevented in this case, and 
that therefore, the treatment was not responsible for this unfortunate 
result : indeed, they regarded the treatment as correct, and the result 
as a triumph of skill, in that any portion of the limb was saved ; the 
leg and foot now remaining being far more useful than any artificial 
leg and foot could be. 

The Hon. Judge, in a speech remarkable for its clearness and libe- 
rality, sought to impress upon the jury the value of the medical testi- 
mony. The jury returned a verdict for Dr. G., allowing the amount 
of his claim for services, w T ith the costs of suit. 

Specimen 121, in Dr. March's collection at Albany, presents a 
similar disposition of the fragments. The fracture is oblique, from 
above downwards and backwards, and the upper portion lies behind 
the lower. It is firmly united by bone, but with an overlapping of 
from two and a half to three inches. The young gentleman Avho 
showed me the specimen remarked that it had been found impossible, 
owing to an ulcer upon the heel, and to other causes, to employ in the 
treatment any degree of extension. 

These two are the only examples which have come under my obser- 
vation in which a fracture at this point has taken this direction. 

Sir Astley Cooper does not seem to have recognized this form of frac- 
ture and displacement. Amesbury has, however, recorded one case, 
which came under his own observation, where, although the bloodves- 
sels and nerves escaped, the bone projected through the skin in the ham, 



408 FRACTURES OF THE FEMUR. 

and finally exfoliated. 1 And he thinks the point of bone may some- 
times so penetrate the artery and injure the nerves as to render ampu- 
tation necessary, in order to save the life of the patient. 

M. Conral also has related a case in which an epiphysary disjunction, 
occurring in a child twelve years old, was attended with a displacement 
of the upper fragment backwards, and amputation became necessary. 2 
I shall refer to this case again. 

I know of no other cases of this rare accident which have been re- 
ported. Lonsdale refers to it as " the rarest direction for a fracture to 
take;" and thinks that in case of its occurrence, the vessels in the 
popliteal space will stand a chance of being wounded; but he mentions 
no example. The popliteal artery hugs the bone so closely at this point, 
that a displacement of the upper fragment in a direction downwards 
and backwards must always greatly endanger its integrity. Indeed, it is 
here that the artery and vein are in the closest contact with each other, 
and with the bone ; an anatomical fact which has been used by Bich- 
erand and others to explain the greater frequency of aneurisms in the 
ham. 

The direction of the displacement, however, in fractures of the shaft 
of the femur, does not always depend upon the direction of the line of 
fracture. In fractures of the upper third, whatever may be the direc- 
tion of the line of fracture, the lower end of the upper fragment inclines 
forwards and outwards, and the upper end of the lower fragment in- 
wards ; unless, indeed, this inclination is controlled by actual entangle- 
ment of the broken ends with each other. 

In the middle third the fragments also generally take the same rela- 
tive position, whatever may be the direction of the fracture; but when 
the fracture takes place at or near the condyles, where the diameter of 
the bone is much greater, the direction of the obliquity determines 
pretty uniformly the direction of the displacement. 

Symptoms. — The symptoms which characterize a fracture of the shaft 
of the femur are those which are common to all fractures, namely, mo- 
bility, crepitus, displacement of the fragments, pain, and swelling, to 
which are added generally a shortening of the limb, with e version of 
the foot and leg. 

Owing to the great amount of muscle covering the thigh, and some- 
times to the swelling which immediately follows the injury, it is often 
very difficult to determine at what precise point the fracture has oc- 
curred, and still more difficult to say whether the fracture is oblique or 
transverse; indeed, this latter question is sometimes decided approxi- 
mately by a reference to the age of the patient rather than by the ex- 
amination of the limb. 

The immediate shortening varies from half an inch to an inch and a 
half, or even more ; and it will average about one inch in the case of 
healthy adults. 

Prognosis. — Whatever may have been the general opinion of experi- 
enced surgeons as to the question of shortening in other fractures, very 

1 Remarks on Fractures, etc., by Joseph Amesbury, vol. i, p. 293. London, 1831. 

2 Archiv. Gen. de Med., torn, ix, p. 2(37. 



FRACTURES OF THE SHAFT OF THE FEMUR. 409 

few certainly have ever claimed that in fractures of the femur a com- 
plete restoration of the bone to its original length was generally to be 
expected. There seem, however, to have existed only certain vague and 
indefinite notions as to the proportion and amount of this shortening, 
and which have had for their basis nothing better than a few imper- 
fectly analyzed observations. 

Says Scultetus (quoting first from Hippocrates) : " 'For the bones of 
the thigh, though you do draw them out by force of extension, cannot 
be held so by any hands ; but when the first intention slacks, they will 
run together again ; for here the thick and strong flesh are above bind- 
ing, and binding cannot keep them down/ — Hippocrates de fract. 
Which Celsus seems to confirm, lib. 8, cap. 10, where he writes as 
follows of the cure of legs and thighs : ' For we must not be ignorant 
that if the thigh be broken, that it will be made shorter, because it 
never returns to its former state.' And Avicenna, lib. 4, fen. 5, saith 
' that it is a rare thing for the thigh once broken to be perfectly cured 
again/ 

"These words admonish us," continues Scultetus, "that we should 
never promise a perfect cure of the thigh ; but rather, using all dili- 
gence, we should foretell that it is doubtful that the patient will be 
always lame ; but when this shall happen from the nature of the frac- 
ture, or, which most frequently falls out, from the impatience of the sick 
person, it may be imputed to our mistake, and, instead of a reward, 
bring us disgrace." 1 

Says Chelius : " Fracture of the thigh-bone is always a severe acci- 
dent, as the broken ends are retained in proper contact with great diffi- 
culty. The cure takes place most commonly with deformity and short- 
ening of the limb, especially in oblique fractures, and those which occur 
in the upper and lower third of the thigh-bone. Compound fractures 
are so much more difficult to treat." 2 

Says John Bell : " The machine is not yet invented by which a frac- 
tured thigh-bone can be perfectly secured." And Benjamin Bell de- 
clares that " an effectual method of securing oblique fractures in the 
bones of the extremities, and especially of the thigh-bone, is perhaps one 
of the greatest desiderata in modern surgery." " In all ages," he adds, 
"the difficulty of this has been confessedly great; and frequent lame- 
ness, produced by shortened limbs arising from this cause, evidently 
shows that we are still deficient in this branch of practice." 3 

Velpeau says that " after fractures of the femur there is no limping 
unless the shortening exceeds three-quarters of an inch ; and the same 
is true if the shortening occurs in the tibia." The reason is, that the 
pelvis inclines toward the shorter limb, and thus compensates for the- 
deficiency in length. In speaking of the various contrivances for 
dressing the fractured femur, he remarks that " most of them fail to- 
obviate the shortening, and produce eschars, anchylosis, or troublesome 

1 The Chirurgeon's Storehouse, by Johannes Scultetus, a Famous Physician and 
Cbirurgeon of Uline in Suevia. London, 1647. 

2 System of Surgery, by J. M. Chelius, translated, etc., by South. First Amer,. 
ed., vol. i, p. 627, 1874. See also p. 625, paragraph 679. 

3 System of Surgery, by Benjamin Bell, vol. vii, p. 21. Edinburgh, 1801- 

27 



410 FRACTURES OF THE FEMUR. 

arrests of the circulation. This is the price that is usually paid for 
the employment of these complicated machines, and a shortening of a 
quarter to three-quarters of an inch is not avoided after all. The 
simplest apparatus that will maintain the adjustment of the fractured 
femur, so that union may take place with shortening of only half an 
inch, is the best." 1 

Nelaton holds the following language : 

" A fracture of the body of the femur, with an adult, is always a 
grave accident, inasmuch as it demands so long a confinement to the 
bed, and especially on account of the shortening of the limb, which it 
is almost impossible wholly to prevent; accordingly, Boyer recom- 
mends to the surgeon, from the first day, to announce to the parents 
of the patient the possibility of this accident. With infants, on the 
contrary, it is almost always easy to avoid the shortening." 2 

While Malgaigne declares his opinion on this subject thus, at length : 

" When we do not succeed in drawing back the misplaced fragments, 
end to end, so that they may oppose themselves to the action of the 
muscles, it is impossible to preserve to the member its normal length, 
whatever may be the appareil or method employed. Surgeons are not 
sufficiently agreed upon this question. 

" At a period quite recent, Desault pretended to cure all fractures 
without shortening, and his journal contains several examples. In 
imitation of Desault, various practitioners have modified, corrected, 
and improved the apparatus for permanent extension, and they claim 
to have themselves obtained as complete success. I ought then to 
declare here, in the most positive manner, that I have never obtained 
like results, either in the use of my own apparatus, or with that of 
others, nor indeed where, in pursuance of my invitation, several in- 
ventors have applied their apparatus in my wards. I have examined, 
more than once, persons declared cured without shortening, and yet, 
upon measurement, the shortening was always manifest. The misfor- 
tune of all those who believe that they have obtained those miraculous 
cures is, that they have not even thought of instituting a comparative 
measurement of the two limbs ; I will say even more, that they are 
most generally ignorant of the conditions of a good and faithful meas- 
urement. Sometimes, also, they have been deceived in another way 
— in falling upon fractures which were not displaced, especially with 
young persons; and they have believed that they have cured with 
their apparatus a shortening which had never existed. In short, when 
the fragments are not displaced, or even when they are brought again 
into a contact maintained by their reciprocal denticulations, it is easy 
to cure the fracture of the femur without shortening ; aside of those 
two conditions, the thing is simply impossible. 

" Several distinguished surgeons of our day have acknowledged this 
impossibility, and have renounced, in consequence, permanent exten- 

1 Peninsular Journ. of Med., vol. iii, p. 384; also Memphis Med. Journ., vol. iv, 
■p. 254, 1856. 

2 Elemens de Pathologie Chirurgicale, par A. Nelaton, torn, prem., p. 752. 
Paris, 1844. 



FRACTURES OF THE SHAFT OF THE FEMUR. 411 

sion. They allege, moreover, that an overriding of even three centim- 
etres is of little importance, and occasions no limping. I cannot agree 
with this opinion. I have seen persons walk very well with a short- 
ening of one centimetre ; beyond this limit, either they limp, or they 
have lifted the heel of the shoe, or, in short, the limping is only con- 
cealed by a lateral deviation of the spine. 1 We thus are made to com- 
prehend how a fracture with overlapping is always serious, and how 
cautious we ought to be in our prognosis.' 72 

That the foregoing remarks are intended by the author to be equally 
applicable to other fractures of the shaft of the femur than to those of 
the middle third, is made evident by what he has said before, when 
speaking of fractures of the upper third. 

"The prognosis is sufficiently favorable when the fragments are 
denticulated (engrenees) ; when they ride, on the contrary, we must 
look for a shortening as almost inevitable." 3 

In our own country several of the most distinguished surgeons have 
testified to the constant difficulty, if not impossibility, of curing frac- 
tures of this bone without a shortening. In a suit instituted against a 
surgeon in New York city, for alleged malpractice in the treatment 
of an oblique, comminuted, and otherwise complicated fracture of the 
femur near its condyles, Dr. Mott is reported to have testified that 
" more or less shortening of the limb is uniformly the result after frac- 
tured thigh, even in the most favorable circumstances." 4 

In a very interesting communication made to the author by Jona- 
than Knight, of New Haven, late President of the American Medical 
Association, occurs the following passage : 

"I have seen but few fractures of the femur in the adult, unless of 
the most simple kind, in which there was not some remaining defor- 
mity ; often slight, so as not to impair the usefulness of the limb, and in 
others considerable and apparently unavoidable." Dr. Knight adds, 
however: "In the greater proportion of the fractures in children the 
recovery has been so nearly perfect that no marked deformity or lame- 
ness has followed." 

Dr. Detmold, in his remarks made before the New York Academy 
of Medicine, at its meeting in March, 1855, declared his belief that a 
shortening of the femur always occurs after fracture, and that " but one 
inch of shortening in an average of twenty cases is a good result." 5 

Dr. J. Mason Warren, of Boston, writes to me as follows : " As you 
are making observations on fractures, I would state that, after a long 
and very careful observation, I have never yet seen, either in Boston 

1 Dr. Buck, of New York, thinks that with a shortening of one inch, or even one 
inch and a half, the patient may have " a useful limb, with little or no halting in 
his gait." N. Y. Journ. of Med., vol. xvi, p. 294. 

2 Traite" des Fractures et des Luxations, par J. M. Malgaigne, torn, prem., pp. 
723, '724. Paris, 1847. 

3 Op. cit., p. 718. 

4 Boston Med. and Surg. Journ., vol. xxxiv, p. 450. See also opinions of Drs. 
Beese, Post, Parker, Cheeseman, Wood, etc., in relation to the prognosis in this 
particular case. 

5 New York Journ. of Med., second series, vol. xvi, p. 261. 



412 FRACTURES OF TPIE FEMUR. 

or elsewhere, an oblique fracture of the thigh, in a patient over seven- 
teen years of age, in which there was not some shortening. I have 
had cases shown to me in which it was averred that the limb was not 
shortened, but on measuring myself I have found the fact otherwise. 
In children, I believe that union without shortening may be accom- 
plished.'; 

Dr. Bigelow, of the Massachusetts General Hospital, writes to me, 
May, 1875, as follows: "In our hospital cases shortening is the rule 
in adults. Young subjects do better. Three-quarters of an inch short- 
ening in the adult is a good result, and easily compensated by the pelvis. 
Greater shortening may occur/' 

In a paper published by Dr. Lente in the number of the New York 
Journal of Medicine for September, 1851, he states that he believes the 
average shortening after treatment in the New York City Hospital to 
be three-quarters of an inch ; but subsequently, Dr. Buck, one of the 
hospital surgeons, has furnished Dr. Lente with more exact statistics. 
Says Dr. Buck : 

" After carefully scrutinizing over one hundred cases of fracture of 
the femur, taken from the register of the New York Hospital, and elimi- 
nating such as involved the cervix, or condyles, or belonged to the class 
of compound fractures, there remained an aggregate of seventy-four 
cases, of both sexes, and of all ages from 3 to 63, in which the shaft of 
the femur alone was fractured. In all these cases the difference in the 
length of the fractured limb, resulting from the treatment, was ascer- 
tained by careful measurement with a graduated tape, and the follow- 
ing deductions were drawn from the analysis : 

" Of the 74 cases of all ages, 1 9 resulted without any shortening, a 
proportion of about one-fourth. The average shortening of the remain- 
ing 55 cases was a fraction less than three-fourths of an inch. 

" Seventeen cases in the above aggregate were under 12 years of age, 
of which six resulted without any shortening, a proportion of about 
one-third. The average shortening in the remaining 11 cases was a 
fraction less than one-half an inch. 

"Of the 57 cases over 12 years of age, 13 resulted without any 
shortening, a proportion of about one-fourth ; and the average short- 
ening in the remaining 44 cases was a fraction over three-fourths of an 
inch, 7 ' 1 

Mr. Holthouse, surgeon to Westminster Hospital, states that a care- 
ful examination of fifty cases of fractures of the femur in the various 
London hospitals, made by himself, showed that 90 per cent, (includ- 
ing twenty children) were shortened, the amount of shortening ranging 
from one-half an inch to three and one-third ; and as some of these 
cases were still under treatment, he entertains a doubt whether the final 
result will prove to be as favorable as above stated. For himself he 
declares, with a frankness which is most creditable to his courage and 
honesty, that at Westminster, with all the appliances known to surgery 
at his command, he has never succeeded, in the adult, in effecting union 

1 Buffalo Med. Journ., vol. xv, p. 22, June, 1859. 



FRACTURES OF THE SHAFT OF THE FEMUR. 413 

without shortening. He has also examined more than one hundred 
specimens in the various museums of the metropolis, and they are all 
shortened. 

After quoting the opinions of several writers upon this subject, in- 
cluding the author of this treatise, Mr. Holthouse adds in a footnote : 

"Notwithstanding this strong testimony, surgeons are still to be found 
hardy enough, or ignorant enough, to repeat the fallacies which have 
been so often refuted, and to vaunt their success in the cure of oblique 
fractures in the adult without shortening. Why do not these surgeons, 
instead of publishing their cases in the journals, produce their patients 
at some of the medical societies." 1 

It is not to be denied, however, that a few surgeons in all parts of 
the world have claimed, and still continue to claim, in their own prac- 
tice, or from the adoption of their own peculiar plans of treatment, 
much better success. Indeed, some of them do not hesitate to affirm 
that, as a general rule, any degree of shortening is quite unnecessary. 

Mr. Amesbury declares, that when the fracture is in the " middle or 
lower third/' under a "judiciously managed" application of his own 
splint, "consolidation of the bone takes place without the occurrence of 
shortening of the limb, or any other deformity deserving of particular 
notice." 2 

Mr. South, in a note, commenting upon an opposite sentiment ex- 
pressed by Chelius, and already quoted, remarks : " In simple fractures 
of the thigh-bone, except with great obliquity, I have rarely found 
difficulty in retaining broken ends in place, and in effecting the union 
without deformity, and with very little, and sometimes without any, 
shortening. For the contrary results the medical attendant is mostly 
to be blamed, as they are usually consequent upon his carelessness or 
ignorance." 3 

Mr. Hunt, of the Queen's Hospital at Birmingham, who treats all 
fractures with the apparatus immobile of Seutin, has published the re- 
sults of his observations; and of the simple fractures of the femur only 
one presented, after the cure, any degree of shortening ; and he adds 
that all other fractures which he has treated by this method were fol- 
lowed by " equally good results." 4 In relation to which statements, 
Mr. Gamgee exclaims : " This is conservative surgery. What other 
mode of treatment would have given such results ? And those cases 
are not exceptional. Mr. Hunt tells us he has selected them from 
amongst many others equally successful. They accord with the experi- 
ence recorded in my little treatise on this subject; and the works of 
Seutin, Burggrseve, Crocq, Velpeau, and Salvagnoli Marchetti record 
numerous cases no less remarkable and demonstratively conclusive." 5 

1 Holthouse, Holmes's System of Surgery, 2d ed., 1870, vol. ii, p. 866. 

2 Practical Remarks on Fractures, by Joseph Amesbury, vol. i, p. 384. London 
ed., 1831. 

3 Op. cit., vol. i, p. 627. 

4 Researches on Pathological Anatomy and Clinical Surgery, by Joseph Sampson 
Gamgee. London ed., pp. 159, 160. 

6 Op. cit., p. 167. 



414 FRACTURES OF THE FEMUR. 

Desault, also, according to the passage from Malgaigne which I have 
already quoted, "pretended to cure all fractures without shortening." 
I do not find, however, any other authority for this statement, as here 
made ; neither in his Treatise on Fractures and Luxations, edited by 
Bichat, nor elsewhere. Bichat even says positively that " Desault him- 
self did not always prevent the shortening of the limb." 1 He declares, 
however, that " Desault has cured, at the Hotel Dieu, a vast number 
of fractures of the os femoris, without the least remaining deformity." 2 

Dr. Dorsey, of Philadelphia, who employed the apparatus of Desault, 
as modified by Physick and Hutchinson (Fig. 149), was equally suc- 
cessful. 3 



Fig. 149. 




^3 



Physick's splint. — The splint is intended to reach to the axilla, but the counter-extension is made 
by a perineal band. Physick employed a second, long, inside splint. 

Dr. Scott, of Montreal, Professor of Clinical Surgery in the McGill 
College, and Physician to the Montreal General Hospital, has reported 
19 cases of fractures of the long bones, taken promiscuously and without 
selection, from his hospital service, of which 3 belonged to the clavicle, 
7 to the femur, 8 to the tibia and fibula, and 1 to the condyles of the 
humerus. All of which recovered without any degree of shortening 
or deformity ; except the case of fracture of the condyles of the hume- 
rus, which resulted in death. 4 

It is never a pleasant duty to call in question the accuracy of an- 
other's statements as to what he has himself alone seen and experi- 
enced. The circumstances which would justify such an expression 
of skepticism, where the witnesses, as in this case, are presumed to be 
intelligent and honest men, must be extraordinary. Such, however, I 
conceive to be the circumstances in this instance. It is certainly very 
extraordinary that a few gentlemen of acknowledged skill, but whose 
means and appliances are concealed from no one, are able to do what 
nearly the whole world besides, with the same means, acknowledges 
itself unable to accomplish. Such is the fact, nevertheless ; and our 
lack of faith in their testimony is only a necessary result of our expe- 
rience, and of the experience of the vast majority of practical surgeons 
as opposed to theirs. 

I might properly enough dismiss this subject with no farther argu- 
ment than may be found in the overwhelming testimony of practical 
surgeons, that broken femurs do in their experience rarely unite with- 
out more or less shortening ; but I cannot avoid calling attention to 

1 A Treatise on Fractures and Luxations, etc., by P. J. Desault, edited by Xav. 
Bichat. Amer. ed.,p. 251. 1805. 

2 Op. cit., p 223. 

3 Elements of Surgery, by John Syng Dorsey, vol. i, p. 163. Philadelphia, 1813. 

4 " Medical Chronicle," of Montreal, vol. i, No. 7, 1853. 



FRACTURES OF THE SHAFT OF THE FEMUR. 415 

the evidence of the falsity of the opposite opinion, which is furnished 
by the testimony of the very persons who themselves claim to have 
obtained such fortunate results. 

It is not, as might have been supposed, one particular form of dress- 
ing, which, in itself peculiar, and more perfect than all others, has fur- 
nished these results. On the contrary, the plans of treatment have 
been constantly unlike, and sometimes quite opposite. Thus, Desault 
used a straight splint, with extension and counter-extension, and he re- 
fused to adopt the flexed position recommended by Pott, because his 
experience, and the experience of other French surgeons, had taught 
him its inutility. 1 Adopting the straight position, he made perfect 
limbs ; with the flexed position he found it impossible to do so. 

Dorsey used the splint of Desault, as modified by Physick and 
Hutchinson. 

South, whose success seems to have been equal to that of Desault 
or Dorsey, adopts also the straight position ; but he makes no perma- 
nent extension, except what may be accomplished through the medium 
of four long side splints applied after " gentle " extension has been 
made by the assistants. 

Mr. Amesbury, on the other hand, made perfect limbs only with his 
own double-inclined plane ; and speaking in general of the various 
plans hitherto contrived, not excepting that invented by Desault, or 
the method practiced by South, which had already been recommended 
by several surgeons, he declares that " they are seldom able to prevent 
the riding of the bone, and preserve the natural figure of the limb. 
Indeed, so commonly does retraction of the limb occur under the use 
of the different contrivances usually employed, that I have heard a 
celebrated lecturer (now retired) in this town publicly assert that he 
never saw a fractured thigh-bone that had united without riding of 
the fractured ends!" 2 And in his General Inferences he uses the 
following emphatic language: " The contrivances which are commonly 
used in the treatment of these fractures do not sufficiently resist the 
operation of the forces abovementioned, but suffer their influence to 
be exerted upon the bone, in all cases more or less injuriously, and at 
the same time often assist in "producing displacement of the fractured 
ends ; so that deformity, differing in kind and degree in different cases, 
is almost the constant result of fractures of the femur treated by these 
means. 

On the other hand, Mr. Gamgee broadly contradicts the statements 
of Desault, South, Dorsey, and Amesbury, and does not hesitate to 
administer a severe rebuke even upon the illustrious Liston : " Pott's 
plan, the long splint, Mclntyre, and their modifications, as a rule entail 
sensible deformity, which in many cases is very considerable. It is a 
significant fact that though the example established in University 
College Hospital by the late Mr. Liston, of treating fractures of the 
thigh by the long splint, and of the leg by the modified Mclntyre (a 

1 Works of Desault, op. cit., p. 225. 

2 Amesbury on Fractures, etc., vol. i, p. 310. s Op. cit., vol. i, p. 384. 



416 FRACTURES OF THE FEMUR. 

double-inclined plane), which are admitted equal, if not superior, to 
other splints, was rigidly followed in that institution, the patients 

Fig. 150. 




Liston's method, recommended by Samuel Cooper, Fergusson, Pirrie, and others. 

admitted with broken thighs or legs were frequently discharged with 
manifest deformity." 1 

With how much force Mr. Gamgee's own remarks as to the expe- 
rience of the University College Hospital will apply to the starched 
bandages used by himself, the reader will be able to determine when 
referred to the opinion of Velpeau, already quoted, who claims no 
result better than an average shortening of half an inch. M. Velpeau 
prefers and advocates the starched bandage, but he does not claim to 
be able to prevent a shortening of the bone. 

" What other modes of treatment would have given such results ?" 
This question, propounded, no doubt honestly, by Mr. Gamgee, has 
here its fair and satisfactory answer. Almost any of the various modes 
named; for if we must receive his testimony, we are equally bound to 
receive the testimony of Desault, South, Dorsey, Amesbury, and Scott. 
If we give credit to Mr. Gamgee, so far as to doubt the statements of 
these latter as to the degree of success claimed by them, by the same 
rule we must doubt his own statements also as to the degree of success 
claimed by himself. This I say with all sincerity and kindness, fully 
believing that these gentlemen are mistaken, and not that they inten- 
tionally misrepresent the facts. 

By a reference to my Report on Deformities after Fractures, it 
will be seen that the average shortening in fractures of the upper third 
of the femur, in the cases examined by me, was about four-fifths of an 
inch ; in the lower third it was a fraction over three-quarters, and in 
the middle third a fraction less than three-quarters of an inch ; and 
the average of the whole number was almost exactly three-quarters of 
an inch (three-quarters and one-forty-seventh). These analyses were 
made upon simple fractures, and were exclusive of those in which no 
shortening at all occurred. An analysis which included also those 
which had not shortened, reduced the average shortening to half an 
inch and about one-tenth. 

An examination of cabinet specimens does not present a result so 
favorable even as this. Of nineteen fractures of the shaft of the femur 

1 Advantages of the Starched Apparatus, by Joseph Sampson Gamgee. London, 
1853, pp. 54/55. 



FRACTURES OF THE SHAFT OF THE FEMUR. 417 

contained in Dr. Mutter's cabinet, not one seems to have been short- 
ened less than one inch. Specimen B 63, fracture of the middle third, 
is united with a shortening of two inches and a quarter ; and specimen 
B 130, imperfectly united after a fracture through the middle third, is 
overlapped three and a half or four inches. 

In conclusion, I wish to say briefly that, in view of all the testimony 
which is now before me, I am convinced — 

First. That in the case of an oblique fracture of the shaft of the 
femur occurring in an adult, whose muscles arc not paralyzed, but 
which offer the ordinary resistance to extension and counter-extension, 
and where the ends of the broken bone have once been completely 
displaced, no means have yet been devised by which an overlapping 
and consequent shortening of the bone can generally be prevented. 1 

Second. That in a similar fracture occurring in children or in per- 
sons under fifteen or eighteen years of age, the bone may quite often 
be made to unite with so little shortening that it cannot be detected 
by measurement; but it must not be forgotten that with children 
especially it is exceedingly difficult to measure very accurately. 

Third. That in transverse fractures, or oblique and denticulated, 
occurring in adults, and in which the broken fragments have become 
completely displaced, it will generally be found equally difficult to 
prevent shortening ; because it will be found generally impossible to 
bring the broken ends again into such apposition as that they will rest 
upon and support each other. 

Fourth. That in all fractures, whether occurring in adults or in 
children, where the fragments have never been completely or at all 
displaced, constituting only a very small proportion of the whole 
number of these fractures, a union without shortening may always be 
expected. 

Fifth. That when, in consequence of displacement, an overlapping 
occurs, the average shortening in simple fractures, w T here the best 
appliances and the utmost skill have been employed, is from half to 
three-quarters of an inch. 

If we consider the muscles alone as the cause of the displacement in 
the direction of the long axis of the shaft, the shortening of the limb, 
other things being equal, must be proportioned to the number and 
power of the muscles which draw upwards the lower fragment. This 
will vary in different portions of the limb, but nowhere will this cause 
cease to operate, nor will its variations essentially change the prognosis. 

I have not intended to say that other causes do not operate occasion- 
ally in the production of shortening, but only that muscular contraction 

1 In the three first editions of this treatise the word " generally " is omitted ; 
but a later experience, with improved appliances, has supplied to me, both in my 
own practice and in the practice of others, a few examples of perfect union under 
the conditions named. The word "generally " was therefore added in the fourth 
edition, and is retained in this. Exactly what percentage of perfect cures may 
reasonably be expected cannot at present be determined, but it is certainly very 
small. It has never been my opinion that a shortening must inevitably result as 
a consequence of the absorption of the ends of the bone. When shortening occurs 
I think it is always, or almost always, the result of overlapping of the fragments. 



418 FRACTURES OF THE FEMUR. 

is the cause by which this result is chiefly determined, and that its 
power will be ordinarily the measure of the shortening. 

Conditions of a Faithful Measurement of the Thigh. — The fact that 
a patient walks without any halt, is no evidence that the limb is not 
shortened. In this regard patients are very unlike; one having a 
shortening of only half or three-quarters of an inch may limp per- 
ceptibly, while another with a shortening of an inch, or even an inch 
and a half, may not limp at all. This has been frequently observed; 
and it will be easily understood if, standing erect with one foot on a 
block one and a half inches in height, the other foot is planted upon 
the floor. It will then be seen that this limb can be brought to the 
floor without disturbing the erect position of the body. Nor is it any 
more a proof that the limb is not shortened because, while in the re- 
cumbent posture, the heel can be brought down to the level of the 
other. 

Measurements made from the umbilicus, or from the symphysis 
pubis, are always indefinite and unreliable. Velpeau's idea of meas- 
uring from the folds of the belly, immediately above the ilium, is un- 
sound. Mr. Bryant's suggestion that we measure from the trochanter 
major, by what he terms the ilio-femoral triangle, in order to determine 
the question of a fracture of the neck, is liable to the very serious 
objection that the exact position of the top of the trochanter cannot, in 
most cases, be clearly determined. 

The method most generally practiced, is to measure from the round 
end of the anterior superior spinous process of the ilium to the internal 
or external malleolus; but even this is not very trustworthy. It is 
exceedingly difficult to fix accurately upon the same point upon the 
two sides, and an error of half an inch is very common when this 
method is adopted. 

The patient should repose upon his back, upon an even surface, with 
the lower extremities as nearly as possible in the line with the axis of 
the body, the two wings of the pelvis being in the same (horizontal) 
line. A flexible, but firm, graduated tape is to be preferred to the 
steel tape measure. The foot being steadied by an assistant, the sur- 
geon should put his thumb-nail against the line where it joins the 
ring, and push his nail into the skin just below the anterior superior 
spinous process of the ilium, pressing firmly up and back, the flat 
surface of the nail resting upon the skin. In this way he will obtain 
a fixed point, and he can obtain an exactly corresponding point upon 
the opposite side. Below 7 , the measurement may be made from either 
malleolus, but the outer has the most defined extremity, and is gener- 
ally to be preferred. In most cases, for some months after the termin- 
ation of the treatment, there is some swelling about the ankle, which 
renders it necessary to use great care in defining the point of the 
malleolus. The thumb-nail of the opposite hand may be used for this 
purpose, resting vertically upon the skin (flat against the lower end of 
the malleolus). The same method may be employed in measuring a 
leg, as in measuring a thigh. 

There may be occasional sources of error, which cannot well be 
avoided. In very rare cases, as the observations of Corydon Le Ford 



FRACTURES OF THE SHAFT OF THE FEMUR. 



419 



have shown, the malleoli of the opposite limbs are of unequal length, or 
one limb may be congenitally shorter than the other. 

Treatment. — All the early surgeons, so far as we know, adopted the 
straight position in the treatment of fractures of this bone, either with 
simple lateral splints, or with long splints, with or without extension, 
or with only rollers and compresses, or with extension alone. 

Such was the unanimous opinion and practice of surgeons until 
about the middle of the last century, at which time Percival Pott wrote 
his remarkable treatise on fractures, a work distinguished for the origi- 
nality and boldness of its sentiments, and which was destined soon to 
revolutionize, especially throughout Great Britain, the old notions as 
to the treatment of fractures, and to establish in their stead, at least for 
a time, w.hat has been called, not inappropriately, the "physiological 
doctrine," the peculiarity of w T hich doctrine consisted in its assumption 
that the resistance of those muscles which tend to produce shortening 
can generally be sufficiently overcome by posture, without the aid of 
extension; and that for this purpose, for example, in the case of a 
broken femur, it was only necessary to flex the leg upon the thigh, and 
the thigh upon the body, laying the limb afterwards quietly on its 
outside upon the bed. 

Very few surgeons, even of his own day, ever gave in their full ad- 
hesion to the exclusive physiological system as taught and practiced 



Fig. 151. 




Double-inclined plane, employed in Middlesex Hospital, London. 



by Pott himself, but multitudes, especially among the English, adopted 
in general his views, only choosing to place the patients upon their 
backs rather than upon their sides, and laying the limbs flexed over a 
double-inclined plane. To the support of this system of Pott's, thus 
modified, Sir Astley Cooper, C. Bell, John Bell, Earle, White, Sharp, 
and Amesbury lent the influence of their great names, and its triumphs, 
so far as the judgment of British surgeons was concerned, soon became 
complete. 

In France, and upon the continent generally, the reception of this 
system was more slow and reluctant; but Dupuytrcn, now for once 
taking ground with his great rival, Sir Astley Cooper, adopted almost 
without qualification these novel views. The decision of Dupuytren 
determined the opinions of a large portion of the continental surgeons ; 
and had it not been for the early and decisive opposition of Desault 
and Boyer, the great surgeon of St. Bartholomew might have con- 
tinued for a long time to have enjoyed a triumph upon the continent, 



420 



FRACTURES OF THE FEMUR. 



and perhaps throughout the world, equal to that which had already 
been decreed to him in Great Britain. 

On this side of the Atlantic, the practice of Pott, at least in so far 
as it applied to the treatment of fractures of the thigh, never gained 



Fig. 152. 




Amesbury's splint. 



a distinguished advocate; and but few ever adopted the practice as 
modified by White, Amesbury, Bell, A. Cooper, etc. 

But whatever may have been the early success of these doctrines, 



Fig. 153. 




Amesbury's splint applied. 



either here or elsewhere, it is certain that a strong reaction has taken 
place, and that gradually, in all parts of the world, the opinions of 
practical surgeons have been settling back into their old channel. It 



Fig. 154. 




Boyer's splint. 



would be difficult to find to-day, in France or Germany, a dozen dis- 
tinguished surgeons who adopt universally the flexed position in the 
treatment of fractures of the femur ; and in England the reaction is, 
if possible, even more complete. 

In my tour of 1844, during which I visited very many of the hos- 
pitals of Great Britain and upon the continent of Europe, and in my 



FRACTURES OF THE SHAFT OF THE FEMUR. 



421 



later tour of 1872, I do not remember to have seen the flexed position 
once employed in the treatment of a broken thigh ; and I shall pres- 
ently show that the straight position is at the present moment very 
generally adopted by the best American surgeons. 

There have been, then, three grand epochs in the history of the 
treatment of fractures of the thigh. 

First. That in which the straight position was universally adopted, 
and which reaches from the earliest periods to the period of the writ- 
ings of Pott, or to about the middle of the last century. 

Second. The epoch of the flexed position, which, inaugurated by 
Pott, had already begun to decline at the beginning of the present 
century, and which may be said to have been completed within less 
than one hundred years from the date of its first announcement. 

Third. The epoch of the renaissance, or that in which surgeons, by 
the vote of an overwhelming majority, have declared again in favor of 
the straight position. This is the epoch of our own day. 

Although American surgeons have generally adopted the straight 
position in the treatment of fractures of the thigh, yet the form and 
construction of the splints employed have been greatly varied. The 
simple long splint of Desault, and the more complicated apparatus of 
Boyer (Fig. 154), have each their advocates; but it is seldom that we 
meet with these, or with any of the other forms of apparatus originally 



Fig. 155. 




Nathan R. Smith's suspending apparatus, or double-inclined plane. 

employed in foreign countries, without noticing that they have been 
subjected to considerable modifications; indeed, most of the straight 
splints as well as double-inclined planes in use at present among 
American surgeons may fairly be regarded as original inventions. 

Nathan Smith, of New Haven ; x Nathan R. Smith, of Baltimore f 
Dr. James McNaughton, of Albany f and Nott, of Mobile, are the 



1 Amer. Med. Rev., published at Philadelphia, 1825, vol. ii, p. 355; also Medical 
and Surgical Memoirs of Nathan Smith, published at Baltimore, pp. 129-141. 

2 Med. and Surg. Memoirs, pp. 143-162. See also Geddings, Baltimore Med. and 
Surg. Journ.,vol. i, 1833 ; and Sargent's Minor Surgery, p. 171. 

3 Trans. Amer. Med. Assoc, vol. x, p. 317. Rep. on Defor. after Frac. 



422 



FRACTURES OF THE FEMUR. 



only American surgeons of distinguished reputation, and with whose 
practice I am familiar, who have recommended exclusively the double- 
inclined plane. 

Fig. 156. 




Josiah C. Nott's double-inclined plane. 

In this apparatus the limb is secured to the splint by vertical pins and leather straps; the upper 
surface of the thigh splint is carved out a little, to fit the thigh ; the two portions are articulated by 
a joint like that of a carpenter's rule, and this joint may be steadied by a horizontal bar underneath. 
For the rest, the drawing sufficiently explains itself. 

Dr. Nathan R. Smith has introduced a modification of the double- 
inclined plane in what is known as his " anterior splint," and which 

Fig. 157. 




Smith's anterior splint. 



is intended also as a suspending apparatus. I have seen' it employed 
lately a good deal in the treatment of gunshot fractures of the thigh 
and leg in our various military hospitals. It is my opinion, however, 



Fig. 158. 




N. E. Smith's anterior splint, applied for a fracture of the thigh. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



423 



that it is more applicable to gunshot fractures of the leg than to those 
of the thigh. 

The splint, if splint it can be properly called, is simply a frame 
composed of stout wire and covered with cloth, which being suspended 
above the limb, allows the limb to be suspended in turn to it by rollers ; 
the rollers passing around both limb and splint from the foot to the 
groin. Wire of the size of No. 10 bougie is usually employed. The 
length of the splint should be sufficient to extend from above the 
anterior superior spinous process of the ilium to a point beyond the 
toes, the lateral bars being separated about three inches at the top and 
one-quarter of an inch less at the lower extremity. 

In the case of a broken thigh, the upper hook, to which the cord 
for suspension is to be fastened, ought to be nearly over the seat of 
fracture, and the lower hook should be placed a little above the middle 
of the leg. 

Fig. 159. 




Palmer's modification of the anterior splint. 

The modification of Smith's anterior splint, suggested by Dr. James 
Palmer, United States Navy, will be sufficiently explained by the ac- 
companying woodcut, 1 Fig. 159. 

1 Amer. Journ. Med. Sci., 1865; also, Mechanical Therapeutics, etc., by Philip 
S. Wales, M.D., U. S. ST., 1867. 



424 FRACTURES OF THE FEMUR. 

Dr. J. S. Hodgen, of St. Louis, Mo., has invented a wire suspension 
splint, which I much prefer to Smith's. The bars of wire are traversed 

Fig. 160. 



Hodgen's suspension apparatus. ' 

with a cotton sacking, upon which the limb is laid. He does not, how- 
ever, advocate its general use, but he has designed it especially for gun- 
shot fractures. 1 

On the other hand, among the advocates of the straight position are 
found the names of Physick, Dorsey, Gibson, Horner, J. Hartshorne, 
H. H. Smith, Neill, R. Coates, H. Hartshorne, Norris, Gross, Buck, 
Markoe, A. W. Stein, Post, J. W. Howe, S. B. Ward, F. Weir, E. 
Mason. 

Says Dr. Gross : " Many years ago, before I had much experience in 
this class of injuries, I occasionally employed the flexed position, but 
I soon found that it was objectionable, on account of the great difficulty 
in maintaining so accurate apposition to the ends of the fragments. Of 
late years I have confined myself entirely to the use of the straight po- 
sition, and I have never had any cause to regret it. In the adult, I 
sometimes employ the apparatus of Desault, as modified by Physick, 
but much more frequently one of my own construction, somewhat upon 
the principle of that of Dr. Neill, described in the Philadelphia Medi- 
cal Examiner for 1855. I have used it for nearly twenty years, and it 
has generally answered the purpose most admirably in my hands. It 
consists simply of a box for the thigh and leg, with a footpiece and two 
crutches, one for the axilla and the other for the perineum, to make the 
requisite extension and counter-extension. With such an apparatus, 
an oblique fracture of the thigh can be treated with great comfort to 
the patient, and with the assurance of a good limb. In children, I have 
effected some excellent cures simply by means of a sole-leather trough, 
well padded, and provided with a footpiece. 

1 Hodgen, Treatise on Mil. Surg., by F. H. Hamilton, 1865, p. 411. 



FRACTURES OF THE SHAFT OF THE FEMUR. 425 

" The great objection to the flexed position is the difficulty of keep- 
ing the ends of the broken bones in apposition ; the upper one having 
a constant tendency to pass away from the inferior. Other objections 



Fig. 161. 




John NeilPs straight thigh splint.— Extension and counter-extension made 



at the same time. 



might be urged against the flexed position, but this is quite sufficient to 
induce me to reject it." 1 



Fig. 162. 



Fig. 163. 




Pelvic belt and perineal strap. (From drawings furnished 
by Dr. L. M. Sargent, Boston, Mass.) 

Fig. 164. 



Footpiece and screw. 




Lateral view of the apparatus, without the belt. 
jO Fig. 165. 




Front view, with folded sheet laid across. 



22i ranS " Am ' Med ' AsS()Cm VoK x; also ' S 3' stem of Surg., by S. D. Gross, 1859, 

28 



426 



FRACTURES OF THE FEMUR. 



Dr. Neill, of Philadelphia, has contrived a very ingenious mode of 
making both extension and counter-extension at the same moment by 



Fig. 166. 




Apparatus applied. 



means of a twisted rope, which is fastened by its two ends respectively 
to the perineal band above and the extending bands below. 



Fig. 167. 




■I 1 - M M * ' 'All H 

Side view of apparatus applied. 



^~3 



J. F. Flagg's thigh apparatus, as used in the Massachusetts General 
Hospital, by Warren, Bigelow, and others, is seen in Figs. 162 to 169 
inclusive. 

Fig. 168. 




" The belt is made of strong webbing, having pockets on each side, 
to receive the long splint. It is also furnished with straps and buckles. 



Fig. 169. 




Figs. 168, 169. Mode of making extension with adhesive plaste 



The perineal strap (Fig. 170), corresponding to the injured side, is kept 
constantly buckled, while the other may be occasionally loosened, or 
left off, as its purpose is only to steady the apparatus. Where the 
straps pass under the perineum, they are covered with wash-leather. 
Before applying the belt, a pillow-case or two may be passed around 
the waist. The padlock is only to be used in case the patient persists 
in unbuckling the straps. The splints being applied with also short 



FRACTURES OF THE SHAFT OF THE FEMUR. 427 

side-splints, junks, containing bran or sand, etc., are to be secured more 
firmly to the limb by bands of webbing and buckles." 

Dr. Bigelow informs me that Flagg's apparatus is not now in use at 
this excellent hospital, and has not been for some time; but I have 
retained the illustrations because they exhibit much ingenuity, and. 
serve to explain the gradual progress of improvement in the treatment 
of these fractures. 

At present, the surgeons of the Massachusetts General Hospital 
employ essentially Buck's apparatus; extension being made by a weight 
and pulley, with the aid of adhesive straps, and counter-extension 
being effected by the weight of the body, by elevating the foot of the 
bed. After which, coaptation splints and junks are applied in the usual 
manner. Ether is employed in all cases before making extension, 
the apparatus being applied at the earliest possible moment. 

The two Warrens, father and son, of Boston; Kimball, of Lowell; 
Sanborn, of Lowell, Mass; Mussey, of Cincinnati, Ohio; J. B. Flint, 
of Louisville, Ky. ; Armsby, of Albany, 1 have also recommended some 
form of the straight splint. Said the late Dr. Mussey : 

"For all fractures of the thigh-bone I employ the extended position 
of the limb. There are but few cases in which extending force is not 
necessary to prevent the degree of deformity 
or shortening which would occur without it. 
Of thirty specimens of fracture of the shaft, 
in my collection, only two are transverse. In 
fractures of the neck, especially with old 
subjects, I sometimes avoid the application of 
any kind of apparatus for permanent exten- 
sion ; but in all cases, whether of the neck or 
"shaft, where such extension is attempted, I 
have found the straight position of the limb 
to be the most reliable." 

Daniell, of Savannah, Georgia, recommends 

,i . i , ... ,i -i. if t_ • i 'j • Perineal band secured with a 

the straight position, the limb being laid m a padlock. 

kind of long box, and the extension being 

made w T ith a weight and pulley. 2 Dugas, of Augusta, Georgia, em- 
ploys the pulley and weight also, but uses the long side-splint instead of 
the box. 3 Howe, of Boston, recommended a similar method in 1824. 4 
Dr. Gurdon Buck, of New York, uses the pulley, without the long 
side-splint. His perineal band is composed of india-rubber tubing, 
" of one inch calibre, two feet in length," stuffed with bran or cotton 
lamp wick, and covered with canton flannel, which covering may be 
renewed as often as may be necessary. The extending bands or adhe- 
sive plasters terminating below the foot in an elastic rubber cord. The 
weight necessary to make suitable extension will vary from five to 
twenty pounds. 

1 Trans. Am. Med. Assoc, vol x. Keport on Deformities after Fractures. 

2 Amer. Jonrn. Med. Sciences, vol. iv, p 330, 1829. 

3 Southern Med. and Surg. Journ., Feb. 1854. 

4 Howe, New Eng. Med. Journ., July, 1824. 



Fig. 170. 




1) 






428 



FRACTURES OF THE FEMUR. 



William E. Horner, of Philadelphia, employed a long outside splint 
extending into the axilla, and padded, so as to avoid the necessity of 
junks; with fenestra, for extending and counter-extending bands; and 
also a foot-piece; and a short inside splint, made to extend from the 
perineum to the bottom of the foot. Across the excavated upper end 



Fig. 171. 




Gurdon Buck's apparatus. 



Fig. 172. 




II / r wmm 



W. E. Horner's thigh-splint. 

of this splint, a strip of leather is stretched to receive the pressure of 
the perineum, while the perineal band is made to pass through two 
firm leather loops on the outside of the splint. 1 

Dr. Joseph E. Hartshorne, of Philadelphia, rejected the perineal 
band altogether, and sought to make the counter-extension by means 
of the internal long splint alone ; and for this purpose he cushioned 
the head of the inside splint, as will be seen in the accompanying 
drawing. The head of the outside splint may also be cushioned, but 

Fig. 173. 




Joseph Hartshorne's thigh-splint. 



not for the purpose of employing it as a means of counter-extension. 
The outside splint is so adjusted to the foot-piece, that it may be re- 



1 Treatise on the Practice of Surgery, by Henry H. Smith. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



429 



moved in case of a compound fracture, without disturbing either the 
extension or counter-extension. 1 



Fig. 174. 




D. Gilbert's mode of making counter-extension and extension. 
1. Anterior and posterior counter-extending adhesive bands, two and a half inches wide, crossing 
each other before they pass through the mortise holes. 2. The same, crossing at the upper part of 
thigh and perineum. 3. Horizontal pelvic band, which maybe three inches wide. 4. Extending 
bands, receiving strap of tourniquet in the hollow of the foot. 5. Tourniquet. 

Dr. David Gilbert, of Philadelphia, has published an account of a 
method of making counter-extension with adhesive strips, which he 
had employed successfully not only in fractures of the thigh, but also 



Fig. 175. 




Gilbert's apparatus applied in a case of fracture of both thighs. 
1. Anterior adhesive counter-extending strips. 2. Distal extremity of posterior adhesive strip of 
the side. 3. Adhesive strip surrounding pelvis, binding the anterior and posterior strips to pelvis. 
4. Inner extremity of the extending adhesive strip, forming stirrup under the foot, to receive the 
strap of the tourniquet. 5. Cicatrix of left thigh. 7, 7. Petit's tourniquet, by which the power was 
applied. 

of the leg, extension being made with the tourniquet of Petit. A 
broad piece of plaster also is made to encircle the pelvis, in order to 
bind down the counter-extending bands more firmly to the body. 
Additional strips are employed when they seem to be required. 2 

H. L. Hodge, also of Philadelphia, adopting the same means of 
counter-extension, namely, adhesive plaster bands, has modified the 
idea of Gilbert by securing the strips of plaster to the sides of the 
body instead of the perineum, and attaching them to an iron rod 



1 Treatise on the Practice of Surgery, by Henrv H. Smith. 

2 Gilbert, Amer. Journ. Med. Sci., April, 1859.^. 410-424. 



430 



FRACTURES OF THE FEMUR. 



which is made to project from the top of the splint beyond the 
shoulders. 1 

Lente, of New York, has also occupied himself in the construction 



Fig. 176. 




H. L. Hoige's method of counter-extension in fracture of the femur. 

of an apparatus by which he hopes, in some measure, to obviate the 
inconveniences of the perineal band, by distributing the pressure 

Fig. 177. 




Lente's thigh splint. 



between the tuberosity of the ischium and the groin. He has, there- 
fore, supplied his splint with an iron brace, extending in a curved line 

1 Hodge, Amer. Journ. Med. Sci., April, 1860. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



431 



from the upper part of the external splint, directly across the body, to 
the median line, and cushioned on its inner surface. To this is attached 
the anterior extremity of the perineal band. By this arrangement the 
pressure is not only in a great measure removed from the groin, and 
from the vessels, etc., on the inside of the thigh, but also the direction 
of the counter-extension is in a line with the axis of the body. The 
posterior extremity of this band is secured, not to the upper end of the 
splint, as is usually done, but to the splint several inches lower down, 
where it will take a more secure hold upon the under surface of the 
tuberosity and nates. Both extremities of the band are elastic. Ex- 
tension is made with a screw, inclosing a strong spiral spring in its 
ferrule, or w T ith adhesive plasters, a pulley and weight, at the option 
of the surgeon. 

The splint is made in sections, for adaptation to different persons, 
and for convenience in packing. It extends no higher than the alse 
of the pelvis, and is secured to the body at this point by a padded 
pelvic band. The accompanying illustration will sufficiently explain 
the remaining features of the apparatus. 

The apparatus invented by I)r. Burge, of Brooklyn, is both a frac- 
ture-bed and a splint, and was constructed with the same view of re- 
moving pressure from the front of the groin. The principles involved 



Fig. 178. 




Burge's apparatus. 

and the general plan of construction will be sufficiently explained by 
a study of the accompanying woodcuts. 

There are a few, however, of our most distinguished surgeons, who 
retain the flexed position in certain fractures, such as an oblique down- 
ward and forward fracture, occurring just below the trochanter minor, 
and a similar fracture just above the condyles, or in certain cases of 
fractures in children, or in very old people, but who, nevertheless, give 
a decided preference to the straight splint in those oblique fractures of 
the shaft which constitute by far the greatest proportion of all these 
accidents. Among these, I will mention the names of Nott, of New 
York, Pope, of St. Louis, Mo., and Eve, of Nashville, Tenn. Drs. 
Parker and Weir, of this city, retain the double-inclined plane only in 
fractures of the upper third. 

At the " German Hospital," in this city, under the observation of 
Drs. Krakowizer and Guleke, visiting surgeons, five cases are reported 
as having been treated by Buck's extension and one by plaster of Paris. 
Buck's extension had given the best results. At the " Presbyterian 



432 



FRACTURES OF THE FEMUR. 



Hospital," also, Dr. D. M. Stimson reports that Buck's extension is 
generally employed. Drs. Gouley, Mason, Sayre, Sands, of Bellevue 



Fig. 179. 




i.-..- .,■''.'. ., ... -r/^ 



Burge's apparatus applied. 

Hospital, prefer the plaster of Paris. Dr. Alfred C. Post, Professor 
of Surgery in the University Medical College, speaks as follows : 

" My ordinary practice is to treat fractures of the femur by exten- 
sion with a weight and pulley. The method seems to me as nearly 
perfect as any plan of human device can be, in promoting the comfort 
of the patient, in facilitating the urinary and fecal evacuations, and in 
securing union without deformity. In some cases union occurs ab- 
solutely without shortening, and in other cases the shortening is so 
slight as only to be detected by careful measurement. In cases care- 
fully treated by this method it is rare to meet with shortening much 
exceeding half an inch. I have never seen a case of simple fracture 
of the femur treated in this way in which there was any such shorten- 
ing or deformity as I have seen in some cases which have been treated 
by the use of plaster of Paris bandages." 

Says Dr. Weir, of St. Luke's Hospital : 

" In hospital practice, and where in private practice I can myself 
apply plaster, I do it ; but to my students I point out that Buck's 
apparatus is a much safer method for them to use, and generally for 
practitioners whose opportunities for acquiring large experience are 
few : because I find that unless carefully applied and watched, by fre- 
quent reopening, etc., curvature and shortening will sometimes occur 
unperceived, which cannot be the case in Buck's apparatus." 

Dr. Paul F. Eve, Professor of Surgery in the Nashville Medical 
College, employs of late the plaster of Paris, but not as an immovable 
form of dressing. Extension and counter-extension are made as in 
Buck's apparatus, and the limb is exposed to view daily and sponged. 
In order that these necessary examinations may be made the plaster is 
applied according to the Bavarian method, so that it may be spread 
open without breaking the splint. 

The practice of treating fractures of the thigh, as well as all other 
fractures of the long bones, with the roller alone, and without either 
lateral splints or extending apparatus, first suggested by Badley, has 



FRACTURES OF THE SHAFT OF THE FEMUR. 433 

found in this country but one distinguished advocate, the late Dr. 
Dudley, of Lexington, Ky. 1 ~Nor, with all rny respect for that truly 
great surgeon, can I persuade myself that the practice is able to ac- 
complish, in a majority of cases, the indications proposed, nor indeed 
that it is, at least in the hands of inexperienced surgeons, wholly safe. 
Dr. D., of Aberdeen, Miss., has reported to me one example in which, 
after the application of this bandage by a pupil of Dr. Dudley's, to a 
negro slave, who had a fracture of the femur, death of the limb ensued, 
and amputation became necessary. The negro was sixteen years old, 
and healthy ; the fracture was caused by the fall of a tree or of a 
branch, and was simple. The bandage was applied from the toes up- 
wards to the groin, and was not opened for several days, at which time 
the whole limb was found to be in a state of dry gangrene, with the 
exception of the upper two-thirds of the thigh, which was swollen 
enormously, and partially gangrenous as high up as the groin. 

Dr. D. says : "Having heard the history of the case carefully stated, 
observing the leg and the lower part of the thigh to be in a state of 
dry gangrene, and seeing the marks of the bandage visibly impressed 
on the surface, my opinion was made up at the time that the gangrene 
had resulted from pressure of the bandage. The femoral artery at the 
groin was in a sound and natural state, and if I mistake not, after the 
limb was removed, it was traced to the point of obliteration where the 
gangrene commenced, and where the impression of the bandage was 
observed ; thus far, I think, it was of natural size and calibre. Hence 
the conclusion is inevitable, that the death of the limb resulted from 
the pressure of the bandage, and not of one of the fragments. 

"It was a curious specimen of dry mortification, and I regret that I 
did not use the means of preserving it. I was then engaged in a very 
laborious practice, thirty miles from home, on horseback, and conse- 
quently could not conveniently spare the time to attend to it as an 
object of surgical curiosity. Dr. II. and myself cut into the leg in 
various places, in order to examine the muscles, arteries, nerves, etc., 
but found the integuments so hard that it was really difficult to pene- 
trate them with a knife; the resistance to the knife was more like that 
of dry hickory wood than anything else/' 2 

I cannot think it necessary to do more than allude to the practice of 
Jobert, of Paris, and of Swinburn, of Albany, who, rejecting side or 
coaptation splints altogether, have relied solely upon extension as a 
means of support and retention in the case of fractures of the shaft of 
the femur. 

The treatment of these and other fractures by plaster of Paris, paste, 
starch, or dextrin has been already considered when speaking of the 
treatment of fractures in general. Thus far my experience will not 
warrant me in recommending the immovable apparatus as a general 
plan of treatment in fractures of the thigh. 

In the fourth edition I spoke somewhat more favorably of the re- 

1 Amer. Journ. of the Mod. Sei., vol. xix, p. 270; Transylvania Journal, April, 
1836. Boston Med. and Surg. Journ , vol. xxxiv, p. 35. 

2 For a more complete account of this interesting case, see Buffalo Med. Journal, 
vol. xiv, p. 193, Sept. 1858. 



434 FRACTURES OF THE FEMUR. 

suits of this practice as declared by some of the House Surgeons of 
Bellevue ; still more lately one of the visiting surgeons has published 
some statistics which indicate a better average result than has been 
hitherto obtained by other methods; but having since learned that 
these statements were not based altogether upon measurements made 
by these well known and able writers themselves, I am unwilling to 
accept of them as trustworthy testimony. 1 In order to assure myself 
as to whether we were able to make longer and straighter thighs by 
the use of the plaster of Paris than by the method of extension as 
employed by myself and others, my later experience has been carefully 
collated, but not selected ; every case in which the opportunity was 
afforded being recorded, and the results being confirmed by my own 
testimony and the testimony of others. • The facts thus obtained con- 
stituted the basis of an article written by me for the New York Medical 
Journal, and published in the August number for 1874; but the great 
interest taken in the discussion of the merits of the Mathiesson plaster 
of Paris dressings, both in this country and abroad, during the last 
few years, seemed to me to call for a statement of experience which 
should cover a larger number of cases, although it could not be ex- 
pected in a treatise like this to give all the cases in detail, as was done 
in the journal communication already referred to. Of the cases treated 
by plaster of Paris, and recorded in the accompanying tables, a ma- 
jority were from the hands of other surgeons, and all were hospital 
cases; in almost every instance the surgeon treating the case having 
had a large experience in the use of plaster. With very few exceptions 
the plaster was applied while the patient was under the influence of 
ether. After the plaster was applied most of the patients walked 
about with crutches ; but there were pretty frequent examples in which, 
for one reason or another, this was found impracticable, and the patients 
remained in bed. 

The amount of shortening has six times exceeded one inch. A con- 
siderable bend at the seat of fracture has occurred six times ; anchy- 
losis of the knee, requiring surgical interference, has occurred six 
times, and in almost all cases it has been more troublesome than it is 
usually found to be after other plans of treatment; once gangrene, 
amputation and death followed, and once abscesses of the leg, paraly- 
sis, etc., etc. 

The cases reported as treated without plaster were all treated by my- 
self. The method adopted being in the case of adults essentially that 
which is known as Buck's extension, but which I have, as will here- 
after be seen, considerably modified. In the case of children, the 
method has been uniformly that which I shall hereafter describe in its 
proper place as the method preferred by me in these cases; permanent 
extension, such as is used in Buck's apparatus, being very seldom em- 
ployed. Not one of these limbs has presented an excessive shortening 
— one inch being the maximum. Not one is bent at the point of frac- 
ture. None of the patients had bed-sores, or troublesome anchylosis 

i Prof. H. B. Sands, N. Y. Med. Journ., June, 1871. Dr. J. D. Bryant, 1ST. Y. 
Mod. Rpcord, Sept. 15th, 1871. Dr. S. H. St Johns, Amer. Journ. Med. Sci., 
July, 1872. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



435 



at the knee-joint. In one there was delayed union. Case 23 has been 
measured by many of the gentlemen connected with Bellevue, and all 
agree that the broken limb is longer than the other, yet it united 
promptly, and he walks without a halt. We have been unable, thus 
far, to find any other explanation of the increased length but the fact that 
extension was employed, the amount employed being about the same 
as in other cases. Five children and one adult had perfect limbs ; or, if 
we are permitted to include the case in which the limb is lengthened, 
two adults have recovered with perfect limbs. 

Cases treated with Plaster of Paris, Continuous Roller, Mathiesson's method. 



No. 



Age 



Yrs. 

11 

2 15 

16 

17 



5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
29 

30 



Character of 
fracture. 



Simple. 



With frac. 

of legs. 
Simple. 



Point of 
fracture. 



Compound 
Simple. 



Compound. 
Simple. 



Middle. 



Below 
troch. 

Middle. 



Extracap. 
Middle. 



Extracap. 
J Below 
\ troch. 
(( 

Above 
cond. 



Middle. 



Hospital. 


Amount of 
shortening. 




Inches. 


Bellevue. 


f 


St. Francis. 


f 


Park. 


H 


99th St. 


l 


Park. 


l 


Bellevue. 


I 


CI 


I 


u 


l 


(< 


l 


(< 


i 


Park. 


I 


c( 


H 


(C 


l 


it 


1* 


Bellevue. 


i* 


u 


i 


c< 


I 


(( 


1 


99th St. 


if 


Bellevue. 




K 


2 


It 


1 


a 


1 


(i 


3. 

4 


K 


1 


ii 


Perfect. 


u 


H 


Park. 


I 


Bellevue. 


i 


99th St. 





Deformity. 



Slightly 
b«-nt. 



Much bent 



Remarks. 



Bent, 
Much bent 
Bent 



Anchylosis of 
knee. 



{Anchylosis 
broken up 
under ether, 



Anchylosis. 

u 

Delayed union, 
No union. 
Anchylosis. 
Anchvlosis. 



( Paralysis, ab- 
\ scess, etc. 



amp., death, 



436 



FRACTURES OF THE FEMUR. 



Cases treated by myself, by my own and Buck's methods. 



No. 


Age 


Character of 
fracture. 


Point. 


Hospital. 


Shortened. 


Deformed. 




Yrs. 








Inches. 




1 


. 2 


Simple. 


Middle. 


Bellevue. 


* 


Straight. 


o 


6 


u 


u 


" 


Perfect. 


t( 


3 


4 


(i 


a 


Private. 


* t 


M 


4 


6 


(( 


" 


t( 


Perfect. 


it 


5 


10 


C i 


it 


Bellevue. 


(< 


it 


6 


9 


a 


u 


<< 


2 
8 


u 


7 


15 


a 


(( 


<t 


t 


(( 


8 


5 


Compound 


(( 


<( 


Perfect. 


<< 


9 


18 


Simple. 


u 


u 


u 


u 


10 


33 


(c 


(( 


a 


1 


(< 


11 


20 


(i 


u 


u 


1 


t( 


12 


50 


(< 


(( 


t< 


3. 

4 


u 


13 


35 


(i 


(( 


Long Is. C. 


I 


u 


14 


60 


« 


Intracap. 


Park. 


i 


(( 


15 


50 


K 


Extracap. 


u 


l 


(< 


16 


40 


<( 


" 


Bellevue. 


1 


a 


17 


40 


u 


«« 


ci 


l 


(( 


18 


35 


c< 


u 


k 


7 


u 


19 


40 


11 


u 


ci 


i 


u 


20 


60 


(( 


a 


Long Is. 0. 


1 


(< 


21 


45 


(( 


a 


Private. 


J 


(( 


22 


70 


" 


Neck. 


t< 


i 


u 


23 


40 


" 


Above knee. 


Bellevue. 


Lengthened. 


a 


24 


22 


" 


Middle. 


<( 




u 



Remarks. 



Toes everted. 



Dela3 7 ed union. 



It will be seen that the first table includes two cases in which seri- 
ous results ensued. In case 30 gangrene supervened on the third day 
after the accident, and on the second, after the dressings were applied ; 
amputation was made, and the patient died. In case 27 the plaster 
was applied on the fifth day after the accident (November 13th, 1873) 
and removed twenty days later, when the patient found he had no sen- 
sation in the limb below the knee; the leg was also much swollen below 
the knee. Subsequently abscesses formed in the leg, large sloughs oc- 
curred, and the calcaneum became carious. 

Both of the preceding cases are reported at more length in the num- 
ber of the New York Medical Journal for August, 1 874. 

These two constitute the only examples of serious accidents which 
might possibly have been due to the mode of dressing, in this table of 
30 cases, which, as has been already explained, were recorded without 
selection ; but they are not all which have come under the writer's 



FRACTUEES OF THE SHAFT OF THE FEMUE. 437 

notice. In one case at Bellevue an enormous perineal slough was 
caused by the pressure of the plaster. In addition, also, to the case of 
gangrene and death included in the first of the preceding tables, the 
following have to be recorded : 

Lizzie Gibbons, set. 24, fell upon the sidewalk and broke her thigh 
about six inches above the knee-joint. She was carried to Bellevue 
Hospital, and on the same day, under the influence of ether, and with 
limb extended by pulleys, plaster dressings were applied. Twenty- 
four hours later the toes looked dark, and the splint was opened about 
the foot. On the following morning the house surgeon found the limb 
cold, and sensation greatly impaired. The dressings were at once 
opened freely. Death took place on the third day. 

Charles Grim, set. 62, admitted to Bellevue Jan. 2d, 1871, with a 
fracture of the cervix femoris, which had just occurred from a fall on the 
ice. On the fourth day plaster of Paris was applied with aid of ether 
and pulleys. Two days later the record reads : " Patient has a large 
sore on sacrum, extending almost to the loins ; splint taken off; ex- 
tremities cold and blue; pulse felt with difficulty; suffering from some 
dyspnoea; lungs emphysematous, and old fracture (?) somewhere; this 
p.m. he died." 1 

The two following cases deserve to be mentioned in this connection, 
inasmuch as the class of casualties to which they belong are chiefly in- 
cidental to the plaster of Paris method. In no other forms of dressing 
have anaesthetics been employed so universally. 

John Stockander was admitted to Bellevue August 2d, 1872, with a 
fracture of the left femur below the trochanter. Buck's extension was 
applied at first, and on the eighteenth day the patient was placed under 
the influence of ether, the pulleys attached, and the application of the 
plaster commenced. The breathing was soon observed to be gasping. 
Ether was withheld a few minutes, when, as the breathing became 
regular, it was resumed. Soon after the pupils rapidly dilated, the 
breathing ceased, and in a few minutes more, in spite of every effort to 
resuscitate him, death supervened. There is every evidence to sustain 
the opinion that the ether was given carefully and in the usual manner. 2 

In the case of Mary Shules, No. 11 of the second table, ether was 
administered for the purpose of applying plaster; and while extension 
with pulleys was employed, and the bandages were being applied, 
"she suddenly ceased to breathe, and her face became purple." By 
prompt resort to various expedients, including Marshall Hall's method, 
Sylvester's method, and electricity, she was rescued. " Dr. Figaro 
thinks her respiration was completely suspended two or three minutes." 3 
The attempt to apply plaster was then abandoned, and Buck's extension 
substituted, with the result of giving her a limb shortened only three- 
eighths of an inch. 

1 A Comparison of the Kesults of Treatment of 308 Cases of Fracture of the 
Femur, etc., Bellevue Hospital, bv Frederick E. Hvde, M.D. t New York. New 
York Med Jour., October, 1874, p. 368. 

2 Death from Ether, by W. B. Dunning, M.D., Acting House Surgeon, Bellevue 
Hospital. New York Med. Rec, October 1st, 1872. 

3 New York Med. Jour., August, 1874, p. 134. 



438 



FRACTURES OF THE FEMUR. 



It has been almost the constant practice of late, in this country, to 
employ ether and the pulleys while applying the plaster, and this is 
considered one of the great essentials to success. It is proper then to 
put into the account, as against this method, the danger from anes- 
thetics, and to inquire, perhaps, whether the usual danger attending 
the exhibition of these agents is not increased by the condition of forced 
decubitus, and of extension to which the patients are subjected while the 
plaster is being applied. 

A case reported to the South Carolina State Medical Association, in 
1874, by Dr. Robert W. Gibbes, of Columbia, S. C, furnishes the first 
opportunity yet presented to me to observe in the autopsy the result of 
treatment, in. a case in which plaster of Paris has been employed accord- 
ing to the method just described. Dr. Gibbes has been kind enough 
to send me the specimen, and also photographs, from which the accom- 
panying woodcuts are made. 

Mr. J. H. W., set. 83, weighing 165 pounds, enjoying robust health, 
fell eighteen feet, January 2d, 1873, striking, as he thinks, upon the right 
hip. Dr. Gibbes was called and detected a fracture of the right femur 
just below the trochanters. Fifteen hours after the accident, Dr. Gibbes, 
assisted by other surgeons, applied "the plaster of Paris dressing after 
the well-known method in vogue for several years past in Bellevue 
Hospital, my venerable patient being kept for some time suspended 
above the table and fully under chloroform." 

On the fourth day he made an attempt to walk, but the attempt was 



Fig. 180. 



Fig. 181. 




Dr. Gibbes's case. 

Posterior view. Anterior view. 

A, B, C, three fragments ; d, bony bridge. 



not resumed until about the eighteenth day, after which a he began to 
walk around his room daily." The apparatus was removed on the forty- 
third day. The union was firm, and the limb appeared to be shortened 
three-quarters of an inch, as determined by several careful measure- 



FRACTURES OF THE SHAFT OF THE FEMUR. 439 

merits. On the 29th of June, about six months after the accident, he 
died of apoplexy. In the autopsy it was found that the femur was 
broken just below the trochanters into three fragments. 

The result of the treatment, considering his age and weight, was all 
that could have been expected ; and the preference given to the plaster, 
in this particular case, was judicious; but the point to which I desire 
to direct the attention of the reader is, that the specimen does not sus- 
tain the claim made by certain advocates of this method, that it is able 
to prevent a shortening in all cases. In this case there is, according to 
the measurements made before death, a shortening of three-quarters of 
an inch. An examination of the specimen convinces me that it is some- 
what more; but however this may be, one thing is certain, the limb 
shortened to the same degree that it would have done if no apparatus 
whatever had been employed. It shortened until the upper end of the 
lower fragment struck and was arrested by the neck. The apparatus 
enabled the patient to walk sooner than he could otherwise have done ; 
and this is a consideration of more importance often in an old man than 
the length or form of the limb, and I doubt whether any other plan 
would have made the limb in this case any longer. 

It will be necessary to describe a little more in detail than has been 
done in the chapter devoted to the general consideration of fractures, 
the method of applying the plaster of Paris in fractures of the thigh, 
which we usually adopt at Bellevue. 

A plaster of Paris bandage is applied to the foot and leg some hours 
before the complete dressing is made. It is better that this should be 
done twelve or twenty-four hours before, in order that this portion of 
the apparatus may become solid, and not remain liable to be indented, 
or pressed inwards toward the limb when extension is applied, and 
also in order that the surgeon may know, by an examination of the toes 
after the lapse of a sufficient time, that the dressing is not too tight. 

This section of the apparatus should extend from a little above the 
metatarso-phalangeal articulation of the toes to about the junction of 
the middle and lower thirds of the leg. Instead of the soft woollen 
cloth, which is generally to be preferred in the upper part of the limb, we 
may here lay next to the skin a sheet of cotton batting, and this should 
be thicker over the instep and above the heel than elsewhere. We can- 
not take too many precautions in protecting the limb about the ankle 
from undue pressure. It will be remembered, also, that while at the 
ankle the splint should be thick, composed of five or six consecutive 
turns of the roller, it may be light upon the foot, and near the upper 
end of the splint upon the leg. 

While the dressings are being applied, and until they have hardened, 
the foot must be held carefully at a right angle with the leg, and in a 
proper line as to inversion or eversion ; but the assistant must take care 
that he does not, with his hand or fingers, indent the plaster. 

A temporary congestion of the toes almost always ensues upon the 
application of the bandage, but this usually subsides within twenty- 
four hours. If it does not, the bandage is too tight, and must be cut 
open. 

In applying the final dressings on the following day, or when the 



440 FRACTURES OF THE FEMUR. 

first dressing has become solid, the patient is laid upon a bed composed 
of two or three mattresses, or of a sufficient number of folded blankets, 
his loins, shoulders, and head resting upon the bed thus constructed, 
while his hips, thighs, and legs extend beyond the bed. In order to 
support the lower portion of the body in this position a piece of a cotton 
roller, three inches wide and two yards long, having been lubricated 
with sweet oil, is passed under the pelvis, and tied above to a bar sup- 
ported by a stanchion, as seen in the woodcut. Various methods of 
supporting the pelvis have been devised, but this is the most simple and 
efficacious. The piece of bandage is directed to be softened with oil, 
in order that it may be easily withdrawn when the dressing is hard; 
but if it has not formed a cord this may not be necessary, and it is 
sometimes cut off and left inclosed with the splint. 

The iron stanchion, wrapped with woollen cloth, is now brought 
against the perineum, and the pulleys made fast to the foot by a noose 
of cotton bandage. Moderate extension is made, sufficient to support 
and steady the limb, but not sufficient to overcome the shortening. 

The surgeon now wraps the limb, including the pelvis, thigh, and 
leg, down to the first splint, with soft but coarse woollen cloth, cutting 
out portions here and there, and fitting it smoothly to all the irregulari- 
ties of surface, and stitching it loosely, when it is in place, over the 
region of the tuberosity of the ischium and perineum. Where the splint 
is iiable to make undue pressure, two or three thicknesses of cloth may 
be placed, or cotton batting may be used instead. 

Everything being ready, the assistant places the patient completely 
under the influence of an anaesthetic, and then extension is made with 
the pulleys until the limb is restored, if possible, to the same length as 
the other. 

The bandages, filled with dry plaster, and previously soaked a few 
minutes in water, are then applied from below upwards, including, 
finally, the pelvis as high as the loins. At no point must they be 
drawn tightly, but only with sufficient firmness to insure their accurate 
adaptation to the limb. Three, four, or five thicknesses are required, 
according to the size of the limb, or the age of the patient. In front 
of the groin, where the splint is most liable to become broken when the 
patient gets up, there should be laid two or three strips of binder's 
board, or narrow metal strips, tin or zinc. 

After each successive layer is applied, the surgeon will sprinkle a 
little dry powder upon the surface, and smooth it over with his hand 
previously dipped in water. As soon as the plaster is hard, usually 
within twenty or thirty minutes, the suspending apparatus is removed 
and the patient placed in bed. 

Those surgeons who omit to include the foot and ankle in the plaster 
splint do not, I think, avail themselves of the most important and most 
reliable means of making extension in this form of dressing. When 
the limb shrinks the condyles of the femur and the calf of the leg offer 
very imperfect resistance to the action of the muscles of the thigh, and 
extension is often completely lost. Let it be understood, also, that the 
author does not recommend that the perineum shall be made the point 



FRACTURES OF THE SHAFT OF THE FEMUR. 



441 



of counter-extension ; and in this he is sustained by the majority of 
those who have used this dressing. 

The patient can, in most cases, leave his bed by the third or fourth 
day after the splint is applied. If he keeps out of bed the limb will 
not shrink as much, and the necessity for readjustment will less often 



Fig. 182. 




Extension during application of plaster of Paris. 

arise. In case it becomes loose it cannot be refitted by cutting out a 
portion and folding the splint in again, since it is too inflexible, and it 
will not be made to bear upon the same points as before. At Bellevue, 
when a plaster dressing becomes loose it is always removed and a new 
one applied in the same manner as at first. 

Fi<;. 188. 




Extension continued until the plaster is hard. 

Finally, having considered somewhat at length the leading plans of 
treatment which have, from time to time, been suggested and employed. 

•20 



442 



FRACTURES OF THE FEMUR. 



Fig. 184. 



by our best surgeons both at home and abroad, I desire to describe in 
greater detail those methods and forms of apparatus which my own ex- 
perience has taught me to prefer. 

As to posture, my opinions are in accord with the opinions of a vast 
majority of the most experienced surgeons of the present day. The 
straight position will, on the average, give the best results. Careful 
measurements made by myself in several hundreds of cases, a portion of 
which have been published in my statistical tables, 1 have demonstrated 
that the average shortening of. the limb is greater after any method of 
treatment in which the flexed position is employed, than after treatment 
with extension in the straight position. These observations have also 
shown that the flexed position, contrary to the reiterated statements of 
its advocates, is more apt to entail angular deformity. 

There are a few who, rejecting the flexed position in fractures of the 
middle of the shaft, still declare for this position a preference when the 
fracture occurs just below the trochanters, and in the case of fractures 
at the base of the condyles. 

According to Malgaigne, who has devoted especial study to this 
subject, there is no satisfactory evidence in favor of the flexed position 

when the fracture occurs below the tro- 
chanters. It is not directly forwards, 
but forwards and outwards, that the 
lower end of the upper fragment is car- 
ried by the action of the psoas magnus 
and iliacus internus; so that in order to 
meet the supposed indication it would 
be necessary to carry the lower part of 
the limb outwards also, a position which 
would certainly be found inconvenient, 
if not actually impracticable, in the ma- 
jority of cases. Nor can the tendency 
of the upper fragment to advance in the 
forward direction, and consequently to 
separate from the lower, be met effectu- 
ally by posture alone, unless the thigh 
is completely flexed upon the body. In- 
deed, it is apparent that the position of 
moderate flexion will rather favor the 
action of those muscles which are sup- 
posed to be chiefly responsible for the 
displacement. When the thigh is ex- 
tended upon the body, the psoas magnus 
and iliacus internus are acting in the 
direction of, and parallel to, the axis of 
the femur, and consequently to a disadvantage; but when the limb is 
lifted, their action is more nearly at a right angle with the shaft, and 
their ability to displace the fragment is greatly increased. 

Moreover, it ought to be understood that broken bones are seldom 




Fracture of femur just below trochan 
ter minor. 



Fracture Tables, by F. H. Hamilton, 1853. 



FRACTURES OF THE SHAFT OF THE FEMUR. 443 

or never displaced or separated, in the same manner they would be if 
they were not surrounded with many other structures which have suf- 
fered little or no disruption : they pass each other, but do not separate 
widely, being held together by shreds of periosteum, muscles, tendons, 
ligaments, etc. The same happens when this bone is broken just below 
the trochanters; the upper fragment lies always, or almost always, in 
immediate contact with the lower, and whatever force is brought to 
bear upon the lower fragment more or less directly influences the 
upper; we can then by extension, applied to the leg, draw down not 
only the lower fragment, but we can drag into line the upper fragment. 
No doubt in this attempt we shall meet with some resistance from the 
muscles above named ; but experience has always shown that even 
moderate extension, applied steadily and without interruption, seldom 
or never fails to overcome the resistance of the most powerful muscles. 
We constantly avail ourselves of this principle in overcoming the ab- 
normal contraction of muscles in connection with diseased joints, in the 
reduction of old dislocations, and in many other ways. 

Whatever the advocates of flexion in fractures of the femur may say 
to the contrary, they are never able in this position to employ effective 
extension and counter-extension. A careful examination of all the 
double-inclined planes which have been brought under my notice, 
including Nathan R. Smith's and Dr. Hodgen's suspending apparatus, 
will convince any experienced observer that such is the fact. What- 
ever other excellences they may possess, this does not belong to them. 
But extension is, of all the indications of treatment, that which is of 
the greatest importance in nearly all fractures of the thigh, and no less 
important in the upper third than in the lower. In fact, the higher 
we ascend in the limb, the greater is the tendency to shorten, as my 
measurements have shown, in consequence of the action of those pow- 
erful muscles which, arising above, have their insertions into the lower 
fragment. 

In the case of all those double-inclined planes where the body rests 
upon a bed, there can be no counter-extension except the weight of 
the pelvis and its contents. It will not do to fasten the pelvis to the 
bed by bands, as every one who made the experiment would soon 
learn; nor will the groin tolerate the pressure of counter-extending 
splints or bands. These things have been tried in a thousand ways, 
and abandoned. The weight of the pelvis alone, not of the entire 
body, is the only counter-extending force which can be made available, 
and this is wholly insufficient. In Nathan R. Smith's anterior sus- 
pension splint, not even the weight of the pelvis is employed as a means 
of counter-extension, the pelvis being secured to the splint by rollers, 
equally with the thigh and leg. 

After all, I prefer to leave this question to the verdict of experience, 
and happily this seems to be conclusive, if we may accept the almost 
unanimous testimony of those surgeons who have enjoyed the largest 
hospital practice. In my own experience the ordinary double-inclined 
planes have constantly given the worst results, both in regard to length, 
and lateral displacement ; they are the most difficult to manage, and 
are the most fatiguing to the patients. Nathan R. Smith's suspending 



444 FRACTURES OF THE FEMUR. 

apparatus permits the limb to shorten more than the present methods 
of extension j and it affords inadequate support along the centre of the 
shaft, in consequence of which the limb is apt to unite with a backward 
curvature or angle. In some gunshot fractures treated by this appar- 
atus this posterior curve or angle has been excessive. 

Even the old methods of extension were preferable to flexion ; but 
they had always two serious drawbacks. First, in the excoriations 
and ulcerations incident to the application of extending bands or gaiters, 
or whatever else was employed for this purpose. Again and again I 
have seen ulceration of the instep, of the integuments above the heel, 
and of other parts of the foot and ankle, from extending bands ; and 
second, from similar excoriations, ulcerations, and deep sloughs about 
the groin and perineum, caused by the counter-extending band. It is 
true these accidents did not occur often, and sometimes they were due 
wholly to negligence ; but in order to avoid them we were compelled 
to limit very much the amount of extension, and to exercise unceasing 
vigilance. Only recently, at Bellevue, an attempt was made to employ 
counter-extension in the perineum of an adult, by plaster of Paris 
applied in the usual manner for a broken femur, and as a consequence 
a perineal slough was soon formed two or three inches in depth by 
several inches in length. Lente, the Burges, myself, and others sought 
to overcome some of the difficulties of the perineal band by various 
contrivances ; and perhaps in some measure we have been successful, 
but still the danger of ulceration existed wherever much force was 
employed, or the integuments were unusually delicate. Gilbert's plan 
of substituting adhesive plasters for the usual counter-extending band, 
and Buck's plan of employing elastic tubing, possess no real advan- 
tages. The truth is, there is no point about the groin, perineum, or 
pelvis upon which, by one surgeon or another, the pressure has not 
been made, and more or less distributed, and there is no method per- 
haps which has not been employed, yet, after a fair trial, the results 
are the same. The pressure must be moderate, or serious accidents 
will occasionally happen. 1 

Hodge's attempt to make the counter-extension from the sides of 
the trunk by strips of adhesive plaster, as already described, is wholly 
inefficient in a large majority of cases. 

Our first great step of progress in the treatment of fractures of the 
thigh consists, then, in having secured counter-extension by the weight 
of the body alone, and this is accomplished by simply elevating the 
foot of the bed from four to six inches. I have not used a perineal 
band, except in case of children, for eight or ten years ; and in the case 
of children the weight of the body is still my chief reliance. None 
of my colleagues at Bellevue use the perineal band to-day. 

The second step of progress was the introduction of the method of 
extension by adhesive plasters, weights, and pulleys, without which 
we would be unable to employ effectively the weight of the body as a 
means of counter-extension, and by the use of which all danger of 

1 For cases of sloughing, etc., from perineal band, see N. Y. Journ of Med., 
vol. xiv, 2d ser., p. 261, March, 1856; also same journal, Jan. 1840, p. 239. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



445 



excoriation, ulceration, and sloughing about the foot is completely 
avoided. The suggestion of adhesive plaster extension has been 
claimed for both Dr. Gross and Dr. Wallace, of Philadelphia, and for 
Dr. Swift, of Easton, Pennsylvania; but, however this may be, to Dr. 
Josiah Crosby, of New Hampshire, is certainly due the credit of hav- 
ing brought it conspicuously before the profession. 1 

As to the bed upon which the patient is to repose, it seems proper 
to say that, whenever the circumstances of the patient will warrant 
the expense, a bed constructed with especial view to fractures of the 
thigh ought to be regarded as an essential part of the apparatus ; 
always contributing to the comfort of the patient, if it is not absolutely 
necessary to the attainment of the most complete success. Indeed, 
where some form of fracture-bed cannot be procured, or extempora- 
neously constructed, and the patient is compelled to lie upon a com- 
mon cot-bedstead, or a common post-bedstead, or upon the floor, I 
cannot think the surgeon ought to be held in any degree responsible 
for the result. 

The fracture- beds in use among American surgeons are exceedingly 
various, among which I will mention, as being especially ingenious, 
the beds invented by Jenks, Daniels, the Burges, Addinell Hewson, 
of Philadelphia, 2 J. Rhea Barton, B. H. Coates, of the same city, 3 and 
J. Crosby, of Manchester, N. H. 4 



Fig. 185. 







Jenks's fracture-bed. (From Gibson.) 

Of these several contrivances, Jenks's bed (Fig. 185) has been for the 
longest period in use among American surgeons, and its excellences 

1 New Hampshire Journ. Med., 1851 ; Trans. Amer. Med. Assoc, vol. iii, p. 382. 

2 Hewson, Amer. Journ. Med. Sci., July, 1858, p. 101. 

3 Eclectic Repertory, 5th and 9th vols. 

4 Crosby, Treatise on Milit. Surg., by Frank H. Hamilton, 1865, p. 413. 



446 



FRACTURES OF THE FEMUR. 



most thoroughly tested. It is composed of " two upright posts about 
six feet high, supported each by a pedestal ; of two horizontal bars at 
the top, somewhat longer than a common bedstead ; of a windlass of 
the same length, placed six inches below the upper bar; of a cog-wheel 
and handle; of linen belts, from six to twelve inches wide; of straps 
secured at one end to the windlass, and at the other having hooks 
attached to corresponding eyes in the linen belts; of a head-piece 
made of netting ; of a piece of sheet-iron, twelve inches long, and hol- 
lowed out to fit and surround the thigh ; of a bed-pan, box, and 
cushion to support it, and of some other minor parts. 

" The patient lying on this mattress, and his limb surrounded by the 



Fig. 186 




E. Daniels's fracture-bed. 

"A (Fig. 186) represents a platform of suitable length and width, supported by four legs, a. To the 
upper surface of the platform is attached a cross-piece, b, at a short distance from the centre, and 
directly through the centre of the platform is made a circular hole, c (in dotted lines), said hole 
having a semicircular cut or recess in the cross-piece b. To the straight edge of the cross-piece b 
there is attached, by hinges, d, a board, B, termed the body plane, the width of which may corre- 
spond with that of the platform A, and when depressed its outer edge may be even with the edge of 
the platform. The sides of the body plane may be elevated, or raised so as to be slightly concave on 
its outer surface. To the opposite side or edge of the cross-piece b, and at each side of the semicircular 
cut or recess formed by the aperture c, there are attached by hinges, e, cast-iron plates, C, C, which 
are provided with grooves or ways at their sides, in or between which plates D D work. The plates 
C C, D D (one on each side) are thigh plates, and their edges are provided with projections,/, in 
which a shaft, g, works, one on each plate C. On each shaft g there is placed a pinion, which gears 
into a rack attached to the under surface of the plates D D. At one end of the shafts g are attached 
ratchets, g', in which pawls,,/, catch, said pawls being attached to the sides of the plates C C. To the 
outer edges of the plates D D are attached by hinges, k, boards, E E; these boards are leg planes, 
and are slightly raised at their inner ends, where they are connected to the plates D, in order to form 
depressions to correspond to the shape of the legs. To the under surface of each leg plane there is 
attached a metal guide, I, in which a rack, to, works; the outer ends of the racks have bars, n, pro- 
jecting from them at right angles. To each leg plane is attached a shaft, o, having a pinion, p, and 
ratchet, q, thereon, and pawls, r, which catch into the ratchets, q, the pawls being attached to the 
outer sides of the leg planes. The pinions gear into the racks to. The body plane, and also the thigh 
and leg planes, are covered by a suitable mattress, E, with a hole made through it to correspond with 
the hole in the platform A, and the mattress is slit or cut to cover properly the thigh and leg planes 
without interfering with their movements. To the under side of the platform is attached by hinges 
a flap, F, having a stuffed pad or cushion, t, upon it, which, when the flap is secured upwards against 
the platform, fits in the hole in the platform and mattress. This flap is secured against the platform 
by a button, m." 



FRACTURES OF THE SHAFT OF THE FEMUR. 



447 



apparatus of Desault, Hagedorn, or any other that may be preferred, 
the surgeon, or any common attendant, will only find it requisite to 
pass the linen belts beneath his body [attaching them to the hooks on 
the ends of the straps, and adjusting the whole at the proper distance 
and length, so as to balance the body exactly], and raise it from the 
mattress by turning the handle of the windlass. While the patient is 



Fig. 187. 




thus suspended, the bed can be made up, and the faeces and urine evac- 
uated. To lower the patient again, and replace him on the mattress, 
the windlass must be reversed. The linen belts may then be removed, 
and the body brought in contact with the sheets." 1 



Fig. 188. 




E. Daniels's fracture-bed. 



But in my own experience no bed has proved so complete and 
universally applicable as the fracture-bed invented more recently by 
Daniels, of Owego, New York, and which may be used either as a 



1 Gibson's Surgery, vol. i, 



320. 



448 



FRACTURES OF THE FEMUR. 



double-inclined plane or as a single horizontal plane suitable for the 
support of the patient when his limb is dressed with the straight splint. 

Sometimes I have had constructed a simple frame, covered with a 
stout canvas sacking, having a hole at a point corresponding with the 
position of the nates, and this I have laid directly upon a common 
four-post bedstead. A mattress and one or two quilts must be placed 
upon the boards of the bedstead underneath the sacking, and a sheet 
or two above the sacking, upon which last the patient is to be laid. 
In arranging the linen underneath the patient, the most convenient 
plan is, instead of using only one sheet, which will require that a hole 
shall be made in it corresponding to the hole in the sacking, to employ 
two sheets, and, doubling them separately, to bring the folded margin 
of each from above and from below to the centre of the opening. 
When the patient has occasion to use the bed-pan, it is only necessary 
that two or four persons should lift this frame, and place under each 
corner a block about one foot in height, or it may be raised by a pulley 
and ropes suspended from the ceiling. 

The " invalid-bed," to which I have already alluded as a " fracture" 
bed, invented by Dr. Josiah Crosby, of Manchester, N. H., and which 
was introduced into many of the United States general hospitals by order 



Fig. 189. 




Crosby's invalid-bed, closed. 

of the Surgeon-General, has been found to be of great service, not only 
in the management of invalids, in the general sense of that term, but 
also in the treatment of gunshot fractures of the thigh. Indeed, I 
have had occasion to use this bedstead in Bellevue Hospital, and I can 
say that its value in many cases can scarcely be overestimated. 

We may also floor over a common bedstead, having previously, in 
case it is an adult whom we have to treat, removed the foot-board, so 
that we may extend the floor two or three feet beyond the usual length 
of the bedstead. In the centre of this floor we may make an opening, 
so arranged as to be closed by a board slid underneath, or by a door 
fastened with a couple of leathern hinges, and closed by a spring catch. 

A very comfortable bed, especially for children, can sometimes be 



FRACTURES OF THE SHAFT OF THE FEMUR. 



449 



made from a cot. But it will be necessary always to nail a piece of 
board firmly across the top and bottom of the bedstead when the sack- 
ing is at its utmost tension, in order to prevent the side rails from 



Fig. 190. 




Crosby's invalid-bed, open. 
The bed is movable, and can be run out from under the patient and changed It is then run back, 
the hooks B being made fast to the catches A. By turning a crank at C, the rail D is revolved, which 
winds up a strap passing over the pulley (J, and the bed is raised to its position, thus taking off the 
weight of the patient from the bands by which he was temporarily suspended. 

falling together. The top board must be nailed on vertically, like an 
ordinary head-board, so as to prevent the pillows from falling off, but 
the bottom piece should be at least one foot wide, and laid 
horizontally to support and steady the apparatus as it ex- fig. 191. 
tends beyond the foot. 

Having had occasion to assist the late Dr. Treat in the 
management of a fracture of the thigh in the case of a 
little girl not quite three years old, I was struck with the 
simplicity and completeness of an arrangement which he 
had made to prevent the bed and the dressings from be- 
coming soiled with the urine. It was only to leave directly 
underneath the nates a complete opening through to the 
floor for the escape of the urine, and to protect the margins 
of the sacking and sheets, which came nearly together at 
the opening, with pieces of oiled cloth folded upon them- 
selves. It was found that not only the bed was in this way 
kept dry, but the dressings also ; it being now observed 
that the dressings had become wet heretofore by soaking 
up the moisture from the bed, rather than by the direct 
fall of the urine upon them. 

Having prepared the bed for the reception of the pa- 
tient, and elevated its lower end about four inches by standard. 
placing blocks underneath the foot-posts, the following 
additional preparations should be made before we proceed to reduce the 
fracture and dress the limb : 

There should be provided a piece of board of the requisite length 
and breadth, furnished with a slot to receive the pulley, and called the 
" standard," a small iron rod, a pulley, a yard of rope, and a vessel or 




450 



FRACTURES OP THE FEMUR. 



bag to receive the weights. The slot should have sufficient length, and 
the standard should be perforated in the direction of its breadth at short 
distances, to enable the surgeon to elevate or depress the pulley, as may 
be required. In case a metallic pulley cannot be obtained, a spool will 
answer as a tolerable substitute. The adhesive plaster which I have 
generally used both in private and hospital practice is that which is 
usually found in drug stores, spread upon linen ; but some of my col- 
leagues prefer the plaster spread upon jeans or canton-flannel, as being 
stronger. I cannot, however, appreciate their advantage, since the ordi- 
nary plaster seldom gives way, when properly applied. 

A thin block or piece of board, called the " foot-piece," is to be pro- 
vided, perforated in the centre to receive the cord, and of sufficient 
length to prevent the adhesive strips or " extension bands" from press- 
ing upon the malleoli. An average size for the foot-piece in the case 
of an adult is about three inches and three-quarters in length, by two 
and a half in breadth. 

The adhesive plaster may be cut in the shape shown in the illustra- 
tion : five and a half inches wide in the centre, and two and a half 

inches wide at the narrowest point, 
fig. 192. and gradually widening again to- 

war4 each extremity to four inches ; 
the narrower portions being slit 
down two-thirds of their length. 
For an adult we generally require 
a strip of about four feet and eight 
inches in length, namely, sixteen 
inches for the central and widest 
portion, and twenty inches for each 
Foot-piece. extremity. The shoulders of the 

central portion are cut as repre- 
sented, in order that when folded upon the foot-piece and upon itself 
it may reinforce the lateral bands at their weakest points. 




Fig. 19S. 




Extension-band and foot-piece. 




The lateral or side-splints may be made of stout leather, cut and 
moulded to the limb, or of thin pieces of board covered with cotton 



Fig. 194. 




Same, folded and ready for use. 



cloth, and stuffed on the sides next to the skin with cotton batting to 
fit all the inequalities of the limb. The cotton cloth must be stitched 
over the splints like a sac, but left open at the ends until the padding 



FRACTURES OF THE SHAFT OF THE FEMUR. 451 

is properly adjusted. Loose cotton batting always becomes displaced. 
Four splints are generally required : one for the anterior surface, ex- 
tending from the groin below the anterior spines of the pelvis to within 
half an inch of the patella ; one for the posterior surface, extending 
from the tuberosity of the ischium to a point two inches below the 
knee ; one for the inside, extending from near the perineum to the inner 
condyle ; and one for the outside extending from above the trochanter 
major to the outer condyle. These splints ought to encircle the limb 
completely, only leaving an interval of from half an inch to one inch 
between each of the adjacent splints. The outer and inner splints 
may be extended below the knee when the fracture is low down ; but 
in that case they must be carefully fitted to the irregularities of the 
condyles. The posterior splint is the most important of them all. It 
should be wider and longer than either of the other splints, and it 
must be fitted with great accuracy to the back of the thigh, ham, and 
upper part of the leg. It is important also to cover this with a sac of 
cotton cloth so that it may be stitched to the centre of the bands, 
which are to inclose all the splints. If this is not done, it is very 
liable to become displaced. 

A long side-splint must now be prepared, long enough to extend 
from about four inches below the axilla to five inches below the heel ; 
four and a half inches wide, by half an inch in thickness, and provided 
with a cross-piece at the lower end, two feet long by three inches wide 
and half an inch thick. The purpose of this splint is not to make ex- 
tension or to serve as a side coaptation splint, but solely to prevent 
eversion of the foot, which purpose is never accomplished effectively 
by junks or by any other method I have yet seen adopted. It is to be 
employed in all fractures of the thigh, including fractures of the neck. 
The inner surface of this long splint must be padded through its 
whole length, and thus fitted accurately to the sides of the body and 
limb. 

Four or six strips of cotton cloth, each two inches wide by one yard 
in length, are now stitched by their centres to the outer surface of the 
long back-splint, and these are laid upon the bed in position for the 
splint to receive the limb. 

Supplied with rollers, several additional strips of bandage, and 
cotton-batting, we are now ready to reduce and dress the fracture. 

The patient being placed in position upon the bed, one assistant 
seizes the limb by the knee, and a second by the foot, drawing upon it 
firmly and steadily, while the surgeon lays the extremities of the ex- 
tension strips upon each side of the leg, with the centre, containing the 
foot-piece and the rope, about one inch below the sole of the foot. 
With a muslin roller, inclosing the limb from near the metatarso-pha- 
langeal articulation to the tuberosity of the tibia, the adhesive strips 
are held in place. As a rule, and especially in the case of women, and 
of persons of a delicate lax fibre, it is well to lay against the tendo 
Achillis, and over the instep, a little cotton batting before applying the 
roller. In some cases I am in the habit of applying a thin sheet of 
cotton wadding over the whole surface of the limb. Any excess of 
the bands at the upper end are disposed of by turning them down, and 



452 



FRACTURES OF THE FEMUR. 



inclosing thorn in a few additional turns of the roller. As soon as the 
application of the adhesive strips is completed the weight may be 
adjusted, and extension applied. The amount of extension required 
for adults will vary from eighteen to twenty-three pounds. In a large 
proportion of cases twenty or twenty-one pounds will be borne without 



Fig. 195. 



^ 


llll! 






. 








/ 



Mode of applying adhesive plaster. 



complaint; and the ability of the patient to tolerate the extension, 
alone limits the amount. Occasionally, even a few pounds, w T hen first 
applied, causes pain in the ligaments about the knee-joint; but in a 
few hours the amount may be increased. It is better to apply eighteen 
or twenty pounds at once, if it can be borne. Lifting the knee slightly 
by a pad placed underneath, will often relieve the pain caused by the 
extension. 

Sometimes, in the case of very muscular patients, and where the 
primary shortening is considerable, I believe we make a positive and 
permanent gain if we place the patient under the influence of chloro- 
form for a few minutes, when the weight is first applied. In these 
cases, as in dislocations, I generally prefer chloroform to ether, for the 
reason that the patient is less liable to muscular contractions when he 
is passing under the influence of the anaesthetic. 

Extension being effected, and the patient already resting upon the 
posterior coaptation splint, the three other side-splints are applied, and 
the whole secured in place by the four or six transverse bands already 
described as attached to the posterior splint ; the bands being tied over 
the front splint firmly. 

It remains only to lay the long splint beside the body, and to secure 
it in place by a few separate strips of bandage. 

From this time onward, the patient should be seen daily, and the 
coaptation splints loosened or tightened from time to time, as may be 



FRACTURES OF THE SHAFT OF THE FEMUR. 453 

required. Ordinarily it is not necessary to disturb the extension until 
the union is completed. The usual time required for consolidation in 
the case of an adult is from six to eight weeks ; but if the bone feels 
pretty firm at the end of four weeks, the extension may be a little re- 

Fre. 196. 




Author's dressings tor fracture of shaft of fern ir, complete. 

laxed. When at length the patient is permitted to leave his bed, a 
pair of crutches are indispensable; and during the following two months 
but little weight should be borne upon the limb. 

Fractures of the thigh in children have generally been found more 
difficult to manage than fractures of the same bone in the adult, owing 
chiefly to the shortness of the limb, the delicacy of the skin, and the 
restlessness of the patient. I have tried nearly all forms of apparatus 
in these cases, including double-inclined planes, boxes, single long 
splints, etc., and the result of my experience is that they are all ineffi- 
cient; and for some years I have employed a mode of dressing, partly 
my own and partly the suggestion of others, but of which I am able 
to say that it never disappoints me in the result obtained ; while it is 
simple, easy of management, and comfortable to the little patients. 

Extension by means of adhesive plaster and a weight employed in 
the same manner as in adults, constitutes a valuable aid in most cases; 
but I cannot say that it is indispensable, since, with children under 
five or seven years, the fractures are pretty often so nearly transverse 
that, when once reduced and well supported by lateral splints, union 
without shortening may generally be expected ; but these results become 
less and less frequent as we advance toward adult life. It is safe and 
proper, according to my experience, to employ in any case extension, 
somewhat according to the following rule. One pound for a child one 
year old, two for a child two years old, and so on, adding one pound 
for every year up to the twentieth. Of much more consequence, how- 
ever, is it to confine, at the same time, both limbs, for as long as one is 
at liberty it is almost impossible to secure any degree of quiet. It is 
of equal importance, in my opinion, to give to the limbs an extended 
rather than a flexed position. 

My plan of treatment, therefore, in the case of children, is in all 
essential respects the same as in adults, except that instead of one long 
side-splint, I employ two. The accompanying illustrations will ex- 
plain more fully my meaning. Two long side-splints connected by a 
cross-piece at the lower ends, and reaching upwards to near the axillse, 
separated a little more widely below than above, so as to render the 



454 



F R A C T U R E S OF THE FEMUR. 



perineum more accessible, are laid upon each side of the body. The 
leg of the broken limb is secured to the long splint with a roller. The 
remainder of the limb, the opposite limb, and the body, are made fast 
with broad and separate strips of cloth. The coaptation splints, in the 
case of children, may be made of binder's board. 

Thus secured and laid upon a bed, such as I have already described 
as appropriate for children, the least possible annoyance will be given 
to the surgeon. The dressings are but little liable to become wet with 
urine, and when the bed is soiled, the child can be taken up with the 
splint and carried to another; indeed, this may be done as often as the 
patient becomes restless or weary, without any risk of disturbing the 
fracture. 



Fig. 197. 



Fig. 198. 




Author's splint for fracture of the femur in 
children. 



Author's dressing for fracture of the femur 
in children complete. 



In case the surgeon desires to use extension with adhesive plaster 
and weights, the necessary apparatus may be made fast to the bed- 
stead, and taken off when the child is moved ; or it may, if thought 
best, be made fast to the foot-piece of the splint. 

Occasionally, with children, I employ, as a means of extra safety, a 
perineal band, drawn moderately tight, and fastened to the top of the 



FRACTURES OF THE CONDYLES. 455 

splint on the side corresponding to the broken limb. The best peri- 
neal band is a piece of soft cotton cloth, one or two yards long, bv 
three inches wide, folded lengthwise, to a flat band of one inch in 
breadth, and inclosing, where it passes through the perineum and 
under the nates, a few thicknesses of paper. The paper prevents its 
drawing into a round cord. Sometimes I place between the paper 
and the folded cloth, on the side which is to be laid next to the skin, 
one or two thicknesses of cotton wadding. To absorb the moisture, 
it is well to lay a piece of sheet lint between the band and the skin. 
The perineal band may be removed daily and renewed ; and the peri- 
neum examined and washed. 

Four or five weeks is generally a sufficient length of time for per- 
fect consolidation, in children under five years of age. 

The treatment of compound fractures of the thigh, caused by gun- 
shot injuries, will be considered in the chapter devoted to gunshot 
fractures. Other badly comminuted and compound fractures of this 
bone are to be managed upon the same general principles as gunshot 
fractures. 

Those compound fractures of the femur which have been caused 
by the thrusting of the sharp fragments through the flesh, and in 
which reduction has been easily effected, have in most cases done as 
well as simple fractures, except that the limb is generally a little more 
shortened. The wound usually soon heals, and the future progress of 
the case is the same as that of a simple fracture. They may be treated, 
therefore, in the same manner as those which have just been described. 

g 5. Fractures of the Condyles. 

(a.) Fractures of the External Condyle. 

Dr. Aiph B. Crosby, 1 of New Hampshire, has published an account 
of a case of simple fracture of the external condyle, in a voung man 
twenty-one years of age, and which happened from a sudden twist of 
the limb, while he was undressing himself to 
bathe. He was " standing on a shelving bank, Fia 199 - 

S ir- 

with the right leg flexed over the left in order to jpBjj^ 
remove his pantaloons; he lost his balance, par- ^^^^, 

tially twisted the leg, and fell to the ground." plfe ^^^ 

Six months after, the fragment was removed by p^^pf^" _: . 

Dr. Crosby, through an incision below the con- J ~"4 i ^;-=-i f =liB 

dyle. The recovery of the young man has been flip -^ ^H 

The accompanying drawing represents the pltlL =|f 

specimen as seen from its lower or cartilaginous ^tal .-.-.-. --y^ 
surface, and of its actual size. >BjiE=fgp' 

John O'Xeill, set. 40, fell down stairs in Dec. ^SS0^ 

1873, bending his left leg under his body, and , Dn Crosby's specimen of 

fracturing the external condyle. About three condyle. 
months later the patient was brought under my 
notice by Dr. Stanley. The patient was able to walk with a slight 

1 Crosby, New Hampshire Journ. of Med , 1857. 



456 



FRACTURES OF THE FEMUR. 



Fig. 200. 



halt ; the fragment, apparently about one inch in diameter, moving 
upwards about half an inch when the leg is flexed, with a distinct and 
painful crepitus. When at rest, the fragment formed a marked pro- 
jection. It is not certain whether the line of fracture entered the 
joint. 

I examined the limb several times during the succeeding two years, 
and found the condition of matters unchanged, except that the useful- 
ness of the limb has steadily improved. Bandages and knee-supports 
have served no useful purpose, and have been laid aside. 

Dr. T. S. Kirk bride has also reported an example of simple fracture 
of this condyle, which was produced by the kick of a horse, the blow 
having been received upon the inside of the knee. When this patient 
entered the Pennsylvania Hospital, Dec. 1834, the knee was much 
swollen, and crepitus was plainly felt, but the fragment was not dis- 
placed ; the muscles upon the outer side, however, were so strongly 
contracted as to abduct the leg, and produce considerable angular 
deformity. The limb could be easily made 
straight, but it returned to its former position 
of abduction as soon as it was released. When 
fully extended, slight bending of the joint did 
not give severe pain ; but when in any degree 
flexed, all motion was very painful. 

The limb was placed in a long straight frac- 
ture-box, and cold applications were made; 
great swelling followed. It was kept extended 
in this manner, or in the long splint of De- 
sault, twenty-eight days; at which time union 
seemed to have taken place, but the motions at 
the joint were very limited, and productive of 
great pain. From this period the limb was 
laid in a splint, so constructed as that the angle 
of the knee could be changed daily. At the 
end of about six weeks he began to walk on 
crutches, and he could then flex the leg to a 
right angle. 1 

Sir Astley Cooper has related a case of com- 
pound fracture of the same condyle, produced by 
falling from a curbstone upon the knees. The 
man died on the twenty-fourth day. On examination after death, the 
external condyle was found to be broken off, and also a considerable 
fragment was detached from the shaft higher up. 2 




Sir Astley Cooper's case of 
fracture of the external con- 
dyle. 



(b.) Fractures of the Internal Condyle. 

Dr. Thomas Wells, of Columbia, S. C, has reported an example of 
fracture of the internal condyle, accompanied with a dislocation of the 
head of the tibia outwards and backwards. The man was about forty 
years old, and intemperate. Dr. Wells was not called until two days 



1 Kirkbride, Amer. Journ. Med. Sci., May, 1835, vol 

2 Sir Astley Cooper, on Disloe., etc., op. cit., p. 239. 



32. 



FRACTURES OF THE CONDYLES. 457 

after the injury was received, when he found the limb greatly swollen 
and gangrenous. The man's account of himself was that while walk- 
ing in the back yard he fell, and thus dislocated his knee, and that he 
was then brought into the house, being unable to stand upon his feet. 
It does not appear that any attempt was made to reduce the limb, 
probably because his general condition indicated that speedy death was 
inevitable. On the fourth day he died. The autopsy disclosed, in 
addition to the dislocation of the tibia, that a thick scale of bone was 
broken from the inner part of the inner condyle, but it remained at- 
tached to the ligaments. 1 

A case reported to me by Dr. Lewis Riggs, a very intelligent sur- 
geon, practicing in Homer, Oneida Co., N. Y., was more successful. 

A lad, set. 15, was kicked by a horse, the blow being received upon 
the right knee. Dr. Riggs saw him within three hours after the acci- 
dent, and found the internal condyle of the right femur broken off, 
carrying away more than half the articulating surface of the joint ; 
the tibia and fibula were at the same time dislocated inwards and up- 
wards, carrying with them the broken condyle and the patella. The 
displacement upwards was about two inches, and the sharp point of 
the inner fragment had nearly penetrated the skin. There was no 
external wound. The knee presented a very extraordinary appearance, 
and the lad was suffering greatly. Being at a distance from town, and 
the Doctor having no chloroform or pulleys with him, he was obliged 
to depend solely upon the aid of five men who were present. The 
first attempt at reduction was unsuccessful ; but in the second attempt, 
when the men were nearly exhausted in their efforts at extension and 
counter-extension, and while the Doctor was pressing forcibly with both 
hands upon the two condyles, the bones suddenly came into position, 
except that the breadth of the knee seemed to be slightly greater than 
the other, a circumstance which was probably due to the irregularities 
of the broken surfaces, which prevented perfect coaptation. 

Neither splints nor bandages were required to maintain the bones in 
place ; but anticipating the probable occurrence of anchylosis, and with 
a view to making "the limb as useful as possible in this condition," he 
was placed upon " a double-inclined plane," which being supplied with 
lateral supports, would also prevent any deflection in either direction, 
in case the limb was disposed to such displacement. 

The subsequent treatment consisted in the use. of cold water dress- 
ings. Very little inflammation followed. A portion of the integu- 
ment sloughed, but the bone was not exposed, and it healed rapidly. 
On the twenty-fourth day Dr. Riggs gave to the joint passive motion, 
and this was repeated at intervals until, at the end of three months, 
he was able to walk with a cane. At the end of a year Dr. Riggs 
examined the leg, and found the knee a very little larger than the 
other, and he could not flex it quite as completely. In all other re- 
spects it was perfect, and the boy himself declared it was as good as the 
other. 

Treatment of Fractures of either Condyle. — The few cases of these 

1 Wells, Amer. Journ. Med. Sci., May, 1832, vol. x, p. 25. 
30 



458 FRACTURES OF THE FEMUR. 

accidents which I have seen reported have been, with one or two ex- 
ceptions, treated in the straight position. In Kirkbride's case any 
degree of flexion was painful, although there was little or no displace- 
ment of the fragment ; and we think we can see, in the relative posi- 
tion of the articular surfaces of the tibia and femur, a sufficient reason 
why the straight or nearly straight position must generally be pre- 
ferred. Whichever condyle is broken, the remaining condyle will be 
sufficient to prevent a dislocation and consequent shortening of the 
limb, unless, indeed, the dislocation has already occurred as an imme- 
diate consequence of the injury. It is very certain that it would not 
take place from the action of the muscles when the limb was straight. 
In the flexed position I can conceive that it might take place, but yet 
not easily. It is not a dislocation of the limb, then, that we seek 
chiefly to avoid, but a deflection of the leg to the right or to the left, 
according as one or the other of the condyles has been broken. It 
will be readily seen that, in order to resist this tendency, nothing but 
the straight position will answer, and that for this purpose it will be 
necessary to lay a long splint upon one or both sides of the limb, and 
to secure the whole length of both thigh and leg to this splint. The 
long fracture-box used by Kirkbride, if well cushioned on all sides, 
seems to me at once to answer most completely this important indica- 
tion, rendering it even unnecessary to employ a bandage, since the 
opposite sides of the box will compel the limb to adopt the proper 
position. 

As to the remainder of the treatment, it must consist essentially in 
the active employment of such means as are calculated to prevent and 
allay inflammation ; especially ought the surgeon not to omit to avail 
himself of so valuable an antiphlogistic agent as cool water lotions. 

As soon as the union is consummated the joint surfaces should be 
submitted to passive motion, in order to prevent anchylosis; and it 
would be better to commence this so early as to hazard somewhat a 
displacement of the fragment, rather than to wait too long. It may 
not, in some cases, be improper as early as the fourteenth day, and in 
nearly all cases it should be practiced as early as the twenty-eighth. 

(c.) Fractures between the Condyles and across the Base. 

Etiology. — A fracture of this character may be produced by a blow 
received upon the side of the limb or upon the lower extremity of the 
femur; sometimes the blow has been received directly upon the patella 
when the knee was bent, and Bichat mentions a case in which it was 
produced by a fall upon the feet. 

Symptoms. — This fracture is easily distinguished from the preceding 
by the much greater mobility of the fragments and by the palpable 
shortening of the limb, since an overlapping of the broken end is here 
almost inevitable. Each fragment may be felt to move separately, 
and the motion will be accompanied with crepitus. 

Prognosis. — The danger of violent inflammation in the joint is im- 
minent, and anchylosis of the knee is to be anticipated as the most 
favorable result, since the joint surfaces are likely to be rendered im- 



FRACTURES OF THE CONDYLES. 459 

movable by fibrinous deposits in their immediate vicinity, and also by 
the adhesion of the muscles to one another and to the bone higher up, 
where the fracture of the shaft has occurred. More fortunate results 
than these may, indeed, be hoped for, inasmuch as they have occasion- 
ally been noticed, but they cannot fairly be expected. 

In a majority of cases such accidents have demanded, either imme- 
diately or at a later period, amputation. If recovery takes place, a 
shortening of the thigh is inevitable. Mr. Canton, of London, has 
twice performed successfully resection of the joint end of the bone in 
such accidents. 1 

Treatment. — Malgaigne saw a patient who had been treated by 
Guerbois with the aid of extension and counter-extension, who was 
confined to his bed five months, and who had at the end of eight years 
very little motion in the joint, and he seems disposed to charge in some 
measure these unfortunate consequences to the position in which the 
limb was placed, namely, the straight position. But, in my opinion, 
it is much more reasonable to suppose that, if the treatment was at all 
responsible for the results, the error consisted in too long and unneces- 
sary confinement, and in too much extension. I suspect that the mere 
matter of position had nothing to do with the anchylosis. Malgaigne 
does not, however, himself recommend anything more than a very 
slight amount of flexion at the knee ; and to this practice I am pre- 
pared to give my assent ; since it will give to the limb a useful posi- 
tion in case anchylosis does occur, and it is not inconsistent with the 
employment of the moderate amount of extension which alone is justi- 
fiable after this accident. If the young surgeon should differ with me 
in opinion as to the necessity or propriety of using great force to retain 
the fragments in place and prevent overlapping, I beg him to consider 
that this fracture probably never happens except from the application 
of an extraordinary force, and that consequently intense inflammation 
and swelling are almost certain to ensue ; and that in some cases, the 
very fact that immediately after the accident, or for some hours suc- 
ceeding, no swelling occurs, or muscular contraction, and that replace- 
ment of the fragments is easily accomplished, is evidence only of the 
great severity of the injury, and that the whole system is lying under 
the shock; to which, if the patient does not succumb, sooner or later 
reaction will ensue, and the fragments will be gradually drawn up 
with a resistless power. The surgeon ought to remember also that to 
make extension in this case, he is obliged to pull upon those very liga- 
ments and tendons about the joint which, having been torn or bruised, 
must soon become exquisitely sensitive. 

The long straight box, already recommended when speaking of 
fracture of one condyle, is equally applicable here; only that it needs 
a foot-board, or some sort of foot-piece to which an extending appa- 
ratus may be secured, and that a pillow should be placed under the 
knee to give the limb the proper flexion. 

Case. — A man was admitted into St. Thomas's Hospital, London, 
Sept. 17, 1816, with a fracture between the condyles, accompanied also 

1 Lancet, Aug. 28, 1858. Trans. London Path. Soc, 1860. 



460 FRACTUKES OF THE FEMUR. 

with a fracture through the shaft higher up, occasioued by being caught 
in the wheels of a carriage while in motion. There was a small wound 
opposite the point of fracture, and the external condyle was displaced 
outwards. 

The limb was laid in a fracture-box, and in a position of semi- 
flexion. 

On the 18th of November, the external condyle, having protruded 
through the skin, and being dead, was removed with the forceps, 
bringing with it a portion of the articular surface. 

On the 6th of December he was discharged from the hospital, and 
in February following he was walking without any support, and with 
the free use of the joint. 1 

Case. — A gentleman living about eighty miles from town was thrown 
from his carriage, breaking the left femur just above the condyles into 
many fragments, so that when I saw him on the following day the at- 
tending physician showed me about four or five inches of the entire 
thickness of the shaft which he had removed. The external condyle 
was completely separated from the internal, and was quite movable. 

In this case the attempt to save the limb resulted in the loss of the 
patient's life on the sixth or seventh day. 

(d.) Separation of the Lower Epiphysis. 

M. Coural relates the case of a boy 11 years old, who, while his leg 
was buried in a hole up to his knee, fell forwards, separating the lower 
epiphysis from the shaft, and at the same time driving the shaft behind 
the condyles into the popliteal space. The epiphysis also became tilted 
in such a manner that its lower extremity was directed forwards. The 
limb was amputated. 

Madame Lachapelle mentions a case in which traction at the foot of 
a child in the act of birth caused at the same time a separation of the 
lower epiphysis of the femur and the upper epiphysis of the tibia. The 
child was born dead. 2 

Dr. Little presented to the New York Pathological Society, May 24, 
1865, a specimen obtained from his own practice. A boy, set. 11, 
while hanging on to the back of a wagon, had his right leg caught 
between the spokes of the wheel while it was in rapid motion. A few 
hours after the accident, Dr. Little found the upper fragment of the 
femur projecting through an opening in the upper and outer part of the 
popliteal space. On examination, the wound did not appear to com- 
municate with the knee-joint. Under the influence of an anaesthetic 
the fragments were reduced ; the reduction occasioning a dull cartil- 
aginous crepitus. There was at the time no pulsation in the posterior 
tibial artery, and the limb was cold. The limb was laid over a double 
inclined plane. The following day the upper fragment was again dis- 
placed, and it was found that it could only be kept in place by extreme 
flexion of the leg. This position was therefore adopted and main- 

1 Sir A. Cooper on Disloc, etc., op. cit., p. 239. 

2 Malgaigne, op. cit., t. i, p. 69. 



FRACTURES OF THE PATELLA. 461 

tained ; considerable traumatic fever followed, with swelling, and on 
the thirteenth day a secondary haemorrhage occurred from the anterior 
tibial artery near its origin, and it became necessary to amputate. The 
boy made a good recovery. The specimen showed that the line of 
separation had not followed the cartilage throughout, but had at one 
point traversed the bony structure. 

Dr. Voss at the same meeting remarked that he had met with the 
same accident. There was no protrusion of bone, but an abscess 
formed, and it became necessary to amputate. 

Dr. Buck saw a case which occurred in the practice of Dr. Hugh 
Walsh, of Fordham. The subject was a boy 14 years old, and it hap- 
pened in the same manner as with Dr. Little's patient. 1 I know of 
no other cases of this accident. 



CHAPTER XXIX. 

FKACTUKES OF THE PATELLA. 

Causes. — Of forty fractures of the patella which have been recorded 
by me, thirty-five were the result of direct blows or of falls upon the 
knee. In the remaining five examples the fracture was due solely to 
muscular action ; one, a sailor, aged about thirty years, had caught the 
heel of his boot in a knot-hole in the floor, which threw him back- 
wards, and in the effort to sustain himself the patella was broken trans- 
versely. Dr. Kirkbride has reported a case in which both patellae 
were broken in a similar manner, but at different periods. The patient 
was a girl, set. 29, who was admitted into the Pennsylvania Hospital, 
Oct. 16, 1833. "In falling backwards, and making an effort to save 
herself," the right patella had been fractured. She was dismissed cured 
on the 2d of December, and on the 20th of April following she was 
readmitted, with a fracture of the left patella, produced in the same 
manner as before ; but in her effort to save the right limb, the left re- 
ceived all the strain, and the patella gave way. 2 Dr. Kirkbride records 
another instance of fracture from muscular exertion in a man set. 32, 
who attempted to jump into a cart, by raising his body with his hands 
resting upon the bottom of the vehicle ; 2 and Dr. Hayward, of Boston, 
saw a case in the Massachusetts General Hospital, in a man set. 67, 
which occurred in consequence of a false step in descending a flight of 
stairs. 3 

Pathology. — All the fractures produced by muscular action have 
been found to be transverse, and the same is true generally of fractures 
produced by direct blows ; occasionally, however, we meet with lon- 

1 Little, Voss, Buck, N. Y. Journ. Med., Nov. 1865. 

2 Kirkbride, Amer. Journ. Med. Sci., Aug. 1835, vol. xvi, p. 330. 

3 Hayward, Amer. Journ. Med. Sci., vol. xxx, from New Eng. Quart. Journ., 
July, 1842. 



462 



FRACTURES OF THE PATELLA. 



gitudinal fractures, or with fractures more or less oblique and com- 
minuted. Thirty-two of the fractures seen by me were simple and 



Fig. 201. 



Fig. 202. 





transverse, three were simple and oblique, three were comminuted, and 
two were compound. Dupuytren, A. Cooper, and others, have also 
mentioned cases of longitudinal fracture. 



Fig. 203. 




Fig. 204. 



I have seen a double transverse fracture, or a fracture of both 
patellse, in a man set. 22, who fell from a third-story window, striking, 
he says, upon his knees. He was taken to the Hospital of the Sisters 
of Charity, in Buffalo, and, after a few weeks, made an excellent 
recovery. 

Symptoms. — The symptoms which characterize a transverse fracture 
of the patella are sufficiently diagnostic. The fragments are separated 

from each other, the superior fragment 
being drawn upwards more or less, ac- 
cording to the power and activity of the 
muscles or the degree to which the liga- 
mentous coverings and attachments of the 
patella have been torn. Seldom, however, 
is the interval of separation greater than 
half an inch. But in a few cases the violent 
flexion of the knee has been known to draw 
the upper fragment quite three inches from 
the lower. By passing the finger along the 
anterior surface of the limb with a mode- 
rate degree of firmness, the depression be- 
tween the fragments will be made manifest. 
No crepitus can be expected unless the fragments remain in contact, 




Fragments separated by flexion of 
the knee. 



FRACTURES OF THE PATELLA. 



463 



a condition which is unusual. The patient is unable to stand, and 
especially is the power of extending the leg upon the thigh completely 
lost. Usually a good deal of swelling immediately succeeds the acci- 
dent, and after a time the skin becomes more or less discolored from 
effusions of blood. If the fracture is longitudinal or oblique, a slight 
separation is usually present, but not always very easily detected. 

Prognosis. — One of my patients, who had a comminuted fracture, 
with other serious injuries, died, but not as a consequence of the frac- 
ture. In the following case the fragments appear never to have united, 
although the patient recovered : 

John Sharkie, set. 24, a soldier in the British service, while serving 
in the East Indies, was struck on the right knee while he was in a 
sitting posture, with his leg bent under him. 

He was immediately placed under the charge of the surgeon of the 
89th regiment of infantry. During the first eleven days no splints or 
bandages were applied, on account of the severe inflammation and 
swelling. A compress was then placed over both fragments, and they 
were bound together by rollers, etc. The whole limb was suspended 
on an inclined plane, the foot being made fast to a foot-board. This 
treatment was continued four months. When the bandages were re- 
moved, the limb was badly swollen, and immediately the upper frag- 
ment was drawn up toward the body. Eighteen months elapsed before 
he could walk, even with the aid of a cane. 

March 27, 1855, twenty-nine years after the injury was received, he 
was an inmate of the Buffalo Hospital, and I was permitted to examine 
his knee carefully. 

The lower fragment is not displaced, but when the leg is straight 
upon the thigh the upper fragment lies two and a half inches from the 
lower, and when it is flexed upon the 
thigh the upper fragment is removed five 
inches from the lower. 

There is no ligament or other bond of 
union, so far as I can discover. He walks 
with very little or no halt, but he cannot 
walk fast. 

At my Bellevue Hospital clinic, Jan- 
uary 8, 1866, I presented a man, set. 38, 
who had fractured his left patella trans- 
versely four years before. The fragments 
had united, when he ruptured the liga- 
ment again by a fall. I found a separa- 
tion of three and a half inches, and the 
patient unable to walk except with the 
aid of a leather splint. 

In the case of a man, set. 40, the liga- 
mentous union, at first complete, seems to have subsequently given 
way in part. He called upon me for advice nine weeks after the frac- 
ture had occurred. The patella was surrounded with bony callus, so 
that it was considerably wider than the other. The fragments appeared 
to be united by a short ligament, except on the inner side, where there 



Fig. 205. 




464 FRACTURES OF THE PATELLA. 

was a separation or rupture of the ligament to the extent of one-quarter 
of an inch. The patient explained this by saying that the splint was 
removed at the end of four weeks, and that after a week more he began 
to walk, but that he almost immediately felt it tear or give way on the 
inner side. 

During the autumn of 1865 I examined the leg of Dr. B., a graduate 
of Bellevue Medical College, and found a transverse fracture of the 
right patella with great displacement of the upper fragment. He in- 
formed me that he had fallen six years before, when nineteen years old, 
upon a stone, striking upon the patella. The fracture was recognized, 
and the limb was laid upon a straight splint. At the end of three 
months the limb was removed from the splint, and the union was 
found to be complete, with a separation of the fragments to the extent 
of half or three-quarters of an inch. The knee was much anchylosed. 
Soon after this the upper fragment began to draw up, and at the end 
of a year was as much displaced as it is now. At this moment it is 
displaced three inches, and seems to be held to the lower fragment 
only by a narrow ligament attached to their inner margins. He ex- 
tends and flexes the leg perfectly, and walks without the least halt, 
but this limb wearies sooner than the other. 

February 16, 1866, John Donahue, set. 50, was admitted into my 
wards at Bellevue, with a refracture of the right patella. He stated 
that it was first broken eight weeks before, and that it had united, but 
that the day before his admission, while seated on the ground, he at- 
tempted to rise, and that the ligament suddenly gave way. I found 
the fragments separated one inch, and by pressing the upper fragment 
against the lower a slight crepitus was occasioned. His limb was 
placed upon a single-inclined plane, and union soon occurred. 

Without treating at length of other similar cases, I will state that I 
have met with four more examples of refracture of the patella ; in 
three of which the separation was from three to four inches, and in 
one two inches. In neither of these cases had anything been accom- 
plished by the various modes of treatment employed to effect a reunion. 
Mr. Adams has shown, according to Druitt, that in these cases of wide 
separation there is no union at all by ligament, but that the fragments 
are merely held together by the subcutaneous fascia, somewhat thick- 
ened. 

Dr. Kirkbride has reported a case of ligamentous union of the pa- 
tella, in which the ligament was two and a half inches long, and was 
attached only to the inner margins of the fracture. " He was able to 
walk as rapidly as ever, and without perceptible limping." 1 A similar 
case is reported by Dr. Watson, of New York, in which the fragments 
became separated three and a half inches. 2 In both instances the frag- 
ments were supposed to have united by a short ligament, which had 
become lengthened by premature use of the limb ; in the case reported 
by Kirkbride, the ligament seemed to have partly torn, as in the case 
reported by myself. Dr. Coale presented to the Boston Society for 

1 Kirkbride, Amer. Journ. of Med. Sciences, vol. xvi, p. 32. 

2 Watson, N. Y. Journ. of Med. and Surgery, vol. iii, first series, p. 366. 



FRACTURES OF THE PATELLA. 465 

Medical Improvement, at its April meeting in 1856, a specimen of a 
fractured patella taken from a man sixty-five years old, the fracture 
having occurred ten years before. The fragments were at first so 
closely united that no division between them could be discovered, but 
subsequently they became separated at their outer edges one inch, and 
at their inner edges one-eighth of an inch. 1 

In every instance in which a fracture of the patella has been treated 
by myself, union has taken place at periods varying from twenty -four 
to fifty-eight days, the average being about thirty-eight days. Twenty- 
five cases have united by ligaments, varying in length from one-quarter 
to one-half an inch. These measurements, made upon the living sub- 
ject, may not be mathematically accurate, but they cannot be far from 
the truth. In no case has the function of the limb been in any degree 
impaired by this ligamentous union ; from which it must be inferred 
that a short ligamentous union is as useful as a bony union. Practi- 
cally speaking, my results have been perfect. 

Twice, I believe, I have seen a bony union of the patella. The first 
instance is that to which I have already referred as an oblique or lon- 
gitudinal fracture across one corner of the patella ; and in the other 
example the action of the muscles upon the upper fragment was pre- 
vented by the occurrence of a fracture of the shaft of the femur at the 
same time, which permitted the thigh to shorten upon itself. The 
man was about twenty-five years old, and in a fall from a scaffold had 
broken his left femur, and also the patella. The patella was broken 
transversely near its middle, and also longitudinally near its inner 
margin. The fragments were all distinctly made out. Drs. Lewis and 
Dayton, of Buffalo, were in attendance, and on the fifth day I was 
called in consultation. We dressed the limb with a long straight 
splint, employing moderate extension and counter-extension. The 
patella was covered with strips of adhesive plaster. On the fifty- 
eighth day I found the fragments of the patella united. June 3, 1854, 
five months after the accident, I examined the limb carefully. The 
femur was shortened half an inch, and, although the two main frag- 
ments of the patella were separated half an inch, the bond of union 
seemed to be bone. It was hard, and allowed of no motion in the 
upper fragment separate from the lower. The lateral fragment was 
also apparently united by bone and in place. He had but little motion 
in the knee-joint, yet he walked very well, and was able to pursue his 
trade, as a carpenter, without much inconvenience. 

Sir Astley Cooper succeeded in obtaining a bony union in some lon- 
gitudinal fractures, but in a majority of cases it failed, owing to the 
want of apposition in the fragments. It might seem that it would be 
easy to accomplish apposition in all longitudinal fractures, but expe- 
rience has shown that it is not always, the fragments being kept 
asunder partly by the action of the oblique fibres of the vasti and 
partly by the pressure of the condyles of the femur, especially when 
the leg is slightly flexed. 

Whether the fracture is transverse or longitudinal, a bony union 

1 Coale, Boston Med. and Surg. Journal, vol. liv, p. 402. 



466 



FRACTURES OF THE PATELLA. 



may occasionally be obtained when the fragments are retained in abso- 
lute contact for a sufficient length of time; but the failure to procure a 
bony union is not a matter of consequence, since a short ligament is 
equally useful. 

Post, of New York, has reported three cases of compound fracture 
of the patella extending into the knee-joint, brought to a successful 
termination. 1 I have myself met with one or more similar results. 

In a case mentioned by Eve, of Augusta, occasioned by the kick of 
a horse, and in which amputation became necessary on the tenth day, 
"the knee-joint was found filled with dark grumous blood; a portion 
of the cartilage of the internal condyle of the os femoris was chipped 
off, and the patella broken into a number of fragments." 2 

Lewitt, of Michigan, has related a case of fracture in a lad set. 16, 
produced by striking his knee against a piece of timber, which resulted 
in suppuration of the knee-joint, but from which he finally recovered 
with the perfect use of the limb. The fracture of the patella was ob- 
lique, traversing only its upper and outer margin, and it was never 
much displaced. 3 

Dr. Levergood, of Pennsylvania, has reported a similar case, in which 
it became necessary to open the joint freely, yet it was followed by an 
excellent recovery, only a slight anchylosis remaining at the knee-joint. 4 

Treatment. — The dressing which I have generally employed in the 
treatment of this fracture consists of a single-inclined plane, of suffi- 
cient length to support the thigh and leg, and about six inches wider 



Fig. 206. 




The author's mode of dressing a fractured patella. 



than the limb at the knee. This plane rises from a horizontal floor of 
the same length and breadth, and is supported at its distal end by an 
upright piece of board, which serves both to lift the plane and to sup- 
port and steady the foot. The distal end of the inclined plane may be 



1 Post, New York Journ. of Med., vol. ii, first series, p. 367. 

2 Eve, Southern Med. and Surg. Journ., 1 848 ; also Bost. Med. Journ., vol. 
xxxvii, p. 427. 

3 Lewitt, Medical Independent, Sept. 1856. 

4 Levergood, Amer. Jour. Med. Sci., Jan. 1860. 



FRACTURES OF THE PATELLA. 



467 



elevated from six to twelve inches, according to the length of the limb 
and other circumstances. Upon either side, about four inches below 
the knee, is cut a deep notch. The footpiece stands at right angles 
with the inclined plane, and not at right angles with the horizontal 
floor. 

Having covered the apparatus with a thick and soft cushion carefully 
adapted to all the irregularities of the thigh and leg, especial care being 
taken to fill completely the space under the knee, the whole limb is 
now laid upon it, and the foot gently secured to the footboard, between 
which and the foot another cushion is placed. 

The body of the patient should also be flexed upon the thigh, so as 
the more effectually to relax the quadriceps femoris muscle. 

A roller is now applied to the knee by oblique and circular turns; 
commencing above the patella, and traversing the notch in the splint; 
each successive turn covering more of the front of the knee until the 
whole is inclosed. With a second roller the entire limb must then be 
secured to the splint, this roller extending from the ankle to the groin. 

The great advantage which this mode of dressing possesses is, that it 
does not ligate the leg or thigh completely; since, on either side, between 
the broad margins of the splint and the points where the bandages 
touch the limb, there is a space, more or less considerable, against which 
no pressure is made, and through which the circulation may go on 
without impediment; so that, however firmly the bands are drawn 
across the knee, no swelling occurs in the foot. 

The plan adopted by M. Gama, of Yal de Grace, 1 is similar to that 
which I have now described, but the splint upon which the limb re- 
poses is not so wide, while width is an essential point in the attainment 
of the objects which I propose. 

The dressing and apparatus employed by Wood, of King's College 
Hospital, are very similar to my own, but, as will be seen by the ac- 
companying drawing, the splint is only five or six inches wide. Dr. 
Wood has substituted hooks for the notches. 2 



Fig. 207. 




Wood's apparatus. 



Dr. Dorsey, of Philadelphia, employed a very simple apparatus 
which will serve to illustrate the general plan adopted by many sur- 
geons, both at home and abroad. It is liable, however, to the objec- 



1 Malgaigne, Traite des Fractures, etc., op. cit., p. 

2 Fergusson's Surgery, p. 307. 



764. 



468 



FRACTURES OF THE PATELLA. 



tion already stated, namely, that it interrupts too much the circulation 
of the limb. His apparatus consists of a piece of wood half an inch 
thick and two or three inches wide, and long enough to extend from 
the buttock to the heel ; near the middle of this splint, and six inches 
apart, two bands of strong doubled muslin, a yard long, are nailed. 



Fig. 208. 




John Syng Dorsey's patella splint. 

The splint is then cushioned, and the limb laid upon it, a roller being 
first applied from the ankle to the groin, encompassing the knee in the 
form of the figure of 8 ; after which the two muslin bands are secured 
across the knee in such a manner as that the lower one shall draw down 
the upper fragment, and the upper one elevate the lower fragment. 

A single instance will explain the danger of ligation to which I 
have alluded, and which, although it may be greater in case a starch, 
plaster of Paris, or dextrin bandage is used, exists in some degree, 
whatever material for bandaging is employed, if it is applied to the 
whole circumference of the limb, and constant attention is not paid to 
the progress of the swelling. 

" A vine-dresser, set. 40, of a good constitution, fell and received a 
simple transverse fracture of the patella on the 15th of January. The 
medical officer called upon to attend him applied first a bandage for 
the purpose of drawing together the fragments, and afterwards a 
starched bandage extending from the toes to the upper part of the 
thigh ; the limb was then put upon an inclined plane. The patient 

Fig. 209. 




Sir A. Cooper's method hy circular tapes. 



was visited a few times, but, as he scarcely suffered, the apparatus was 
in no way disturbed. On the first of March (sixteenth day) the at- 
tendant returned to remove the bandage, when the odor arising from 



FRACTURES OP THE PATELLA. 



469 



the limb led him to believe that gangrene had taken place, and Dr. 
Defer was sent for. Dr. Defer found the limb in the following state : 
The toes, which were not covered by the bandage, were completely 
insensible and mummified. The bandage being removed, the gangrene 
was perceived to extend within seven inches of the knee, and was 
arrested in its progress. The foot was cold, and was totally insensible ; 
the epidermis was raised up, and was beginning to be separated from 
the skin. The articulation of the ankle was exposed, and the liga- 
ments destroyed. The bones of the leg were also exposed in their 
lower third, and the tendons were in a sloughy state. Amputation 
was performed, and the patient recovered." 1 

Very little better than the starch bandage, and exposing the patient 
in a still greater degree to the dangers of ligation and strangulation, 
are either of the methods recommended by Sir Astley Cooper. 

Fig. 210. 




Sir A. Cooper's method by a leather counter-strap. 

Mr. Lonsdale's instrument is ingenious, but complicated. It is also 
liable to the serious objection that it forbids almost entirely the use of 



Fig. 211. 




Lonsdale's apparatus for fractured patella. — A B. Two vertical iron bars, each supporting a hori- 
zontal one; these horizontal arms slide upon the vertical bars, but can be secured at any point by 
the screws C D. To the horizontal beams are attached other vertical rods, which are movable, and 
yet fixable by screws, as at E. Finally, to each of these last upright pieces is fixed an iron plate, F F, 
by means of a hinge-joint, which keeps the patella in place. The foot-piece is movable up and down 
upon the main body of the apparatus, and can be made fast at any point, so as to adapt the splint to 
limbs of different lengths. 

bandages, which, while they are capable of doing great mischief when 
they bind the limb too closely, are capable also of proving eminently 



1 Amer. Journ. Med. Sci., vol. xxiv, p. 462, from Gazette Medicale, No. 28. 



470 



FRACTURES OF THE PATELLA. 



Fig. 212. 



serviceable when they press upon certain portions of the limb, and not 
with too much force. 

Malgaigne's hooks or clamps I regard as liable to more serious ob- 
jections, and, notwithstanding considerable testimony in their favor, I 
cannot recommend them. 1 

For the same reason the apparatus invented by the late Dr. Turner, 
of Brooklyn, N. Y., 2 is objectionable. Moreover, all forms of appa- 
ratus which, like this of Dr. Turner's, are secured to the limb by 
straps with intervals, are objectionable, since these straps do not, like 
bandages, give uniform support to the surface of the limb. 

Mr. Hutchinson, of London, has of late omitted to elevate the foot 

in the treatment of this fracture, and he 
thinks that the fragments are maintained 
in apposition with quite as much ease. 3 I 
cannot agree with him that nothing is ever 
gained by the elevation of the foot. On 
the contrary, in the treatment of a certain 
proportion of cases this position will be 
found essential to the best success, while 
in others it may be of little consequence 
whether the foot is elevated or not. 

I have seen in use at the Long Island 
College Hospital a very ingenious apparatus 
devised by Dr. J. H. Hobart Burge, one of 
the surgeons of that hospital ; the frag- 
ments being approximated by well-adjusted 
sole-leather pads, w T hich are operated upon 
by weights, cords, and pulleys. 4 

Lausdale, U. S. N., has contrived an ap- 
paratus similar to that invented by Burge, 
but more simple. 5 

The apparatus devised by Dr. R. E. Beach, 
of Illinois, 6 composed of wire, is essentially 
the same as that employed by Burge, Lons- 
dale, and Lausdale, except that the frag- 
ments are approximated by wire covered 
with buckskin. 

Gibson, of St. Louis, has introduced, in a modified form, the circular 
pad or ring, first devised by Albucasis. 7 Dr. Eve, of Nashville, and 
Dr. Blackman, of Cincinnati, have employed this method, and speak 
of it in terms of high commendation. 8 I cannot think, however, that 




Beach's apparatus. 
Wires in semicircular form (A), 
the posterior part of each segment 
(B) being curved upward and the 
sides a little depressed. A shoulder 
is formed (C) on each side of the 
segments for the reception of the 
two straps (D), which connect them, 
and projects far enough on each 
side to permit the wires to he bent 
downwards at right angles with the 
shoulder, and descend perpendi- 
cularly to the slat or mortise (E), 
which is placed near each end of 
the block (F). 



1 Med. Times and Gazette for 1864, vol. i, p. 86. 
Pvle, of the Middlesex Hospital. 

2 Turner, N. Y. Med. Rec, July, 1867. 

3 Hutchinson, London Hospital Reports, vol. ii. 

4 Burge, N. Y. Med. Rec., April 15, 1868, p. 80. 

5 Lausdale, Wales's Surgery, p. 476. 

6 Beach, R. E., St. Louis Med. and Surg. Journ. 

7 Gibson, Amer. Journ Med. Sci., Jan. 1867, p. 



Report of Eight Cases, by Mr. 



Jan. 
281. 



1875. 



8 Western Journ. Med., May, 1868. Nashville Journ. Med., February, 1867. 



FRACTURES OF THE PATELLA. 



471 



it will be found applicable to any large number of cases, and especially 
to such cases as are attended with much contusion and swelling of the 
soft parts. 

Fig. 213. 




Fig. 214. 



Beach's apparatus applied. 

In case the fracture is oblique or longitudinal, it will only be neces- 
sary to lay the limb in a straight position, so as to prevent that lateral 
displacement of the fragments which has been 
shown to occur when the limb is flexed. It will 
not be necessary to employ a splint, unless the 
patient is unmanageable and demands restraint, 
nor to elevate the foot. After the swelling has 
subsided, a slight amount of lateral pressure, 
accomplished by a few turns of a roller, with 
or without compresses, as the circumstances may 
seem to demand, will complete the mechanical 
part of the treatment. 

I have not mentioned the rapid and some- 
times intense inflammation to which the knee- 
joint is liable after a fracture of the patella ; and 
which is often greatly aggravated by the injudi- 
cious application of bandages. In no instance 
ought the bandages to be applied very tightly 
at the first dressing ; and during the first five 
or six days the patient ought to be seen once or 




Malgaigne's hooks. 



Fig. 215. 




Burge's apparatus for fractured patella. 



472 FRACTURES OF THE TIBIA. 

twice daily, and the most prompt attention given to any complaints of 
pain or soreness about the knee. 

If the swelling and inflammation increase rapidly, it would be far 



Fig. 216. 




Lausdale's apparatus. 

better to remove the bandages altogether for a few days, than to take 
the risks consequent upon their continuance. 

The anchylosis which often follows the recovery of the patient, and 
which is sometimes almost complete, is to be overcome by long-con- 
tinued passive motion ; but great care must be taken not to rupture 
the ligament, as we have already seen happen in some cases. 

Dr. Alfred C. Post, of the New York Hospital, has excised the 
knee-joint in a case of anchylosis of long standing; the limb being so 
much flexed in consequence of a comminuted fracture of the patella, as 
to be not merely useless, but an intolerable incumbrance. The patient 
was a laboring man of about forty years of age. This operation was 
made in preference to amputation, at the request of the man himself. 1 



CHAPTER XXX. 

FRACTURES OF THE TIBIA. 

Development of the Tibia. — The tibia is formed, usually, from three 
centres of ossification — one for the shaft, and one for either extremity. 
Ossification commences in the shaft at about the fifth week of foetal 
life. In the upper epiphysis it appears at birth, and unites with the 
shaft at about the twenty-fifth year. Generally it forms the tubercle, 
but occasionally the tubercle has a distinct point of ossification. The 
lower epiphysis commences to ossify during the second year, and unites 

1 Post, New York Med. Gazette, vol. i, p. 309, Nov. 1850. 



FRACTUEES OF THE TIBIA. 



473 



Fig. 217. 



with the shaft at about the twentieth year. The malleolus internus is 
occasionally formed from an independent centre. 

Etiology of Fractures of the Tibia. — Fractures of the tibia alone are, 
in a large majority of cases, produced by direct blows, such as the kick 
of a horse, or a blow from a stick of wood ; in one 
instance I have seen it broken by a kick from a Dutch- 
man's boot. It is occasionally broken by a fall upon 
the foot, the force of the impulse being expended before 
the fibula gives way, but almost always the fibula breaks 
at the same moment, or immediately after the fracture 
has taken place in the tibia. 

Dr. Proudfoot, of New York, has reported an ex- 
ample of fracture of the tibia in utero, produced in the 
sixth month of pregnancy, by violent pressure upon 
the abdomen. 1 

Pathology, Division, etc. — In an analysis of twenty- 
seven fractures of the tibia, not including fractures of 
the malleoli, six were found to have occurred in the 
upper third, eleven in the middle third, and eight in 
the lower third. Six of the twenty-seven are known to 
have been transverse, or only slightly oblique. It is 
probable, also, that several of the remainder were trans- 
verse. In this respect, therefore, fractures of the tibia 
alone will *be found to differ materially from fractures 
of the tibia and fibula ; but it is only in accordance 
with the general observation that indirect blows pro- 
duce almost constantly oblique fractures, and direct 
blows somewhat more frequently transverse. 

Many examples of fractures of the tibia extending 
into the knee-joint are recorded by surgeons, most of 
which were compound, or otherwise seriously complicated, so as to 
render amputation necessary, and the consideration of which scarcely 
belongs properly to a treatise upon fractures. 

The malleolus internus is broken frequently at the same time that 
the ankle-joint is dislocated, and this accident will be considered in 
that connection. 

Separation of Epiphyses. — We have already mentioned that Madame 
Lachapelle has reported a case of separation of the upper epiphysis of 
the tibia, and of the lower epiphysis of the femur, occasioned by pull- 
ing at the foot during birth. 

Dr. Voss, of New York, has seen a separation of the lower epiphysis 
in a boy 14 years old, who in falling had caught his foot between two 
blocks of wood. The upper fragment protruded through the skin. 
Reduction was effected, but subsequently a portion of the epiphysis 
became necrosed and was removed. He finally recovered with a use- 
ful joint. 2 




Development of 
the tibia. (From 
Gray.) 



1 Proudfoot, Bost. Med. and Surg. Journ., vol. xxxv, p. 268, 1846; from New 
York Journ. Med. 

2 Voss, N. Y. Journ. Med., Nov. 1865, p. 133. 

31 



474 FRACTURES OF THE TIBIA. 

Dr. R. W. Smith has reported a similar ease in a boy 16 years of 
age, and which, having occurred six months before, remained unre- 
duced. The lower end of the shaft was displaced forwards. Richard 
Quain records one other example, in a lad 17 years old, which was 
easily reduced and maintained in position. 1 

Prognosis. — No shortening can occur in this fracture unless one or 
both ends of the fibula are displaced, a complication which I have 
noticed in two instances, but in neither case did the shortening exceed 
one-quarter of an inch ; unless, indeed, the fracture occurs above the 
fibula, or the fibula bends and remains bent, or the comminution and 
direction of the fracture is such at either end as to allow the femur or 
the astragalus to become impacted. I have never recognized either of 
these conditions. 

Occasionally the upper fragment has been slightly displaced forwards. 
With these exceptions, and one other of delayed union which I shall 
presently mention, this bone, in my experience, has been found to unite 
promptly and without any appreciable deformity. Other surgeons 
have noticed occasionally that the upper end of the lower fragment 
has become displaced toward the fibula. Dr. Donne, of Louisville, 
has reported an example of delayed union in a simple transverse frac- 
ture of the upper end of the tibia. The man was intemperate. Ten 
weeks after the accident no union had occurred, and Dr. Donne intro- 
duced a seton, and in about six weeks the fragments were firm. 2 

If the fracture extends into either the knee or ankle-joint, the danger 
of anchylosis is imminent, yet experience has shown that it may some- 
times be avoided. 

When the malleolus is broken off, it generally becomes slightly 
displaced downwards, and in this position a complete bony or liga- 
mentous union takes place. 

Treatment. — The tendency to displacement, in a fracture of the tibia, 
is usually so slight, if it exists at all, that simple dressings, light splints 
of leather, felt, or binder's board, with rest in the horizontal posture 
upon a pillow, fulfil nearly all the indications which are present. The 
following cases will illustrate the usual course of these accidents. 

Mrs. W. fell, Oct. 19, 1848, striking on her right knee, breaking 
the tibia transversely just below the tuberosity. 

The fall was the result of a misstep on level ground, and was at- 
tended with only slight bruising of the soft parts. She says that on 
attempting to rise she discovered what had happened, the bone pro- 
jecting very distinctly, and she pushed and pulled it into place with 
her own hands. 

I dressed the limb by laying it upon a pillow, outside of which 
were placed two broad deal splints, tying the whole snugly together 
with several strips of bandage. At a later period the leg and thigh 
were laid over a double-inclined plane. 



1 New York Journ. Med., June, 1868; from British Med. Journ., Aug. 31, 1867. 

2 Donne, Amer. Journ. Med. Sci., vol. xxviii, p. 524; from Western Journ. 
Med. and Surg., Aug. 1841. 



FEACTUEES OF THE TIBIA. 475 

At the end of six weeks all dressings were removed, and the frag- 
ments were found to have united firmly, and so perfectly as that the 
point of fracture could not be traced. 

Peter Hamil, set. 29, was admitted into the hospital Aug. 31, 1849, 
with an injury to his left leg, which had occurred two days before. A 
young surgeon had examined the limb, and thought the femur was 
broken just above the joint. He had applied a roller from the toes to 
the thigh ; and to the thigh were applied lateral splints. These dress- 
ings were on the limb at the time of his admission, and were not re- 
moved until the next day. I could not then discover any fracture or 
displacement, and the dressings were discontinued, the limb being 
merely laid upon pillows. 

Oct. 4, when examining the limb, I detected a slipping sensation, 
like that produced in a false joint, through the upper end of the tibia, 
and I now easily understood what had been mistaken for a fracture of 
the femur. It was a transverse fracture through the upper end of the 
tibia, and without displacement. 

No splints were afterwards applied, and on the 25th of November, 
three months after admission, he was dismissed, the motion between the 
fragments having ceased, but the knee still remaining quite stiff. 

The presence of inflammation, with other complications, may, how- 
ever, occasionally render the treatment more difficult and the results 
less satisfactory. 

John Mahan, set. 39, admitted to the hospital Feb. 16, 1853, with a 
compound fracture of the right tibia, near the middle of the leg. The 
bone was broken by the kick of a Dutchman. I found the limb much 
swollen and very painful, and I laid it carefully over a double-inclined 
plane, and directed cold water irrigations ; I also directed morphia in 
full doses. The inflammation for several days threatened the complete 
loss of his limb. On the tenth day the distal end of the upper frag- 
ment was projecting in front of the lower, and I depressed the angle 
of the splint and made moderate pressure upon the upper fragment. 
On the twentieth day the fragments were bent backwards, and I placed 
a compress behind. On the thirty-seventh day we took the limb from 
the inclined plane, and trusted alone to side-splints. On the forty- 
fifth day we removed all dressings. The fragments had not united. 
The limb was then laid upon a pillow, and six days later a firm gutta- 
percha splint was applied for the purpose of steadying the bone, but 
the splint was removed daily in order that the leg might be bathed and 
rubbed. He was allowed to sit up. On the fifty-ninth day motion 
could still be perceived between the fragments, and he was directed to 
use crutches. On the ninety-third day the union was found to be firm, 
the upper fragment remaining slightly displaced forwards. 

In case the fracture extends into the knee-joint, it is best to lay the 
limb upon pillows or in a nicely cushioned box, and nearly straight. 
No extension or counter-extension is necessary here any more than in 
other fractures of the tibia alone, nor are lateral splints or rollers 
necessary or proper at first as a general rule; but especial attention 
should constantly be given to the prevention of inflammation, and of 



476 FRACTURES OF THE TIBIA. 

subsequent anchylosis. The omission to employ splints in a case of 
this kind was charged against a surgeon in Vermont as evidence of 
malpractice. I am happy to say, however, that, in this particular case, 
he was sustained by the testimony of the medical men and by the 
verdict of the jury ; but the attempt which the reporter has made to 
defend this as a universal practice in fractures of the leg, or of the 
tibia alone, is unfortunate, and evinces a lack of practical experience. 1 

Whatever position is adopted, and whatever means of support or 
retention are employed, if bandages and splints are applied tightly or 
injudiciously, great suffering and irreparable mischief to the knee-joint 
may be the consequence. 

A man, set. 23, entered the Pennsylvania Hospital, July 18, 1839, 
with an obliqire fracture through the head of the tibia. A physician 
had applied a bandage and splint to the leg, and sent him twenty miles 
to the city, and, on examination after his arrival, the whole limb as 
high as the groin was much swollen, red, and excessively painful. 
The knee-joint was distended and very tender. All dressings were 
immediately removed, and the limb laid in a long fracture-box slightly 
elevated at the foot; cool lotions were applied, and the patient was 
freely bled, both from the arm and by the application of leeches. The 
limb was kept in this position about six weeks, and at the end of two 
or three weeks more he was dismissed, cured. Dr. Norris, who was 
the hospital surgeon in attendance, has, in his report of the case, very 
properly taken this occasion to warn surgeons of the danger of exces- 
sive bandaging and splinting in this kind of fracture, as well as in all 
other fractures of the lower extremities. 2 

Fractures of the malleolus, unaccompanied with any other accident, 
demand only that the limb should be laid upon its outer or fibular 
side, with the foot so supported as that it shall incline inwards toward 
the tibia. In this simple disposition of the limb we have done all 
that can be done by any mechanical contrivance toward approaching 
the lower fragment to the shaft from which it has been broken. 

1 Boston Med. Journ., vol. liv, p. 1, March, 1856. 

2 Norris, Amer. Journ. of Med. Sci , vol. xxiii, p. 291. 



FRACTURES OF THE FIBULA. 477 



CHAPTEE XXXI. 

FRACTURES OF THE FIBULA. 

Development of the Fibula. — The fibula is formed from three centres 
of ossification — one for the shaft, and one for each extremity. Bone 
begins to be deposited in the shaft at about the sixth 

Fir 218 

week of foetal life, in the lower extremity during the 
second year, and the upper extremity during the fourth 
year. The lower epiphysis unites with the shaft about 
the twentieth year, and the upper about the twenty-fifth 
year. 

I have not found any recorded examples of separation 
of these epiphyses. 

Causes of Fracture. — In a record of thirty-two cases I 
have been able to ascertain the cause satisfactorily in 
eighteen, of which number three were the results of falls 
directly upon the bottom of the foot, but which were 
probably accompanied with a twist of the foot, four of a 
slip of the foot in walking on level ground, or on ground 
only slightly irregular, and twelve of direct blows. 

Pathology. — In all of the fractures which have been 
produced by falls upon the bottom of the foot, and in all 
except one produced by a slip of the foot, the accident 
was accompanied with a dislocation of the ankle; the foot 
being turned outwards. In the one exceptional case men- 
tioned, the dislocation may also have occurred, but the fact 
is not known. 

Both Malgaigne and Dupuytren have noticed a dislo- 
cation in the opposite direction, or a turning of the foot Development of 
inwards, more often than a turning outwards. I cannot t£e fibula. (From 
think their observations were carefully made. 

Moreover, in at least seven of the twelve, fractures produced by di- 
rect blows the tibia has been thrown more or less inwards, and conse- 
quently the foot has turned out. 

In twenty-four examples the fracture of the fibula has taken place 
within from two to five inches of the lower end of the bone. Twice 
the external malleolus was broken off, and seven times the internal 
malleolus. 

Four of the fractures occurring in consequence of direct blows were 
compound, and one w T as also comminuted. 

Prognosis. — In a majority of cases, where the fibula has been broken 
from two to five inches above the lower end, the fragments have united 



478 



FRACTURES OF THE FIBULA. 



Fig. 219. 



inclined toward or resting against the tibia; occasionally I have seen 
them displaced backwards or forwards. Once the fibula refused to 
unite altogether. 

The malleoli have generally united nearly or quite in place, but in 
two instances the external malleolus has been found displaced very 
much downwards. 

Of the compound fractures, two required amputation, one was treated 
by resection of the lower end of the tibia, and one died without any 
operation. Douglas has reported a case of compound dislocation with 
fracture of the fibula, which being reduced, he was able 
to save the limb, but not without much difficulty, and the 
ankle remained stiff. 1 Other surgeons have met with 
similar success, but I shall refer to this subject again 
under the head of compound dislocations. 

Of those which recovered, twenty-eight in number, ten 
have been found to have more or less unnatural promi- 
nence of the internal malleolus, and in two of these the 
malleolus, or lower end of the tibia, projects very much. 
In nearly all of these examples the foot appears some- 
what inclined outwards. 

Generally the ankle-joint has remained stiff for some 
time after the bandages have been removed; and prob- 
ably in all cases in which the accident was accompanied 
with a dislocation of the tibia. But this stiffness has 
usually disappeared after a few weeks or months. Twice 
I have noticed considerable stiffness after about six 
months; three times after one year; in one case after two 
years ; and in one case after twenty years the ankle would 
occasionally swell, and become quite stiff. In one case 
it remained almost immovable after twenty years; and in a still more 
remarkable instance, I examined the limb thirty years after the acci- 
dent, when the man was sixty -three years old, and although there ex- 
isted no swelling or deformity, yet this leg was not as muscular as the 
other, and he declared that up to this time the ankle remained quite 
tender to the touch, and that occasionally it became painful. 

When I come to speak of dislocation of the ankle, I shall adopt the 
usual nomenclature, and shall name all those dislocations in which the 
tibia projects inwards from the foot, "inward dislocations of the tibia;" 
yet I have some doubts as to the propriety of this appellation. This 
accident seems to me to have been in general rather a lateral rotation of 
the foot, or of the astragalus, upon the lower articulating surfaces of 
the tibia and fibula. Of all the ginglymoid joints, the ankle approaches 
most nearly in form to a ball and socket-joint, in consequence especially 
of the marked prolongations of the malleolus internus and extern us. 
In other ginglymoid articulations lateral displacements are not unfre- 
quent, but lateral rotation can scarcely by any accident occur. Here, 




Fracture of fibula 
near lower end. 



Boston Med. and Surg. Journ., vol. xxxiv, p. 336, from Southern Journ. of Med. 



FRACTURES OF THE FIBULA. 479 

however, the reverse holds true; lateral displacement is difficult, while 
lateral rotation is comparatively easy of accomplishment. 

The majority of cases which occur, involving a disturbance of the 
relative position of the ankle-joint surfaces, are, I am satisfied, of this 
latter character, viz., lateral rotations within the capsule, rather than 
true dislocations; and although the restoration of the joint surfaces to 
position is, in general, easily accomplished, yet in consequence of either 
a fracture of the fibula or malleolus intern us, or of a rupture of the in- 
ternal lateral ligaments, it will generally happen that some deformity 
w T ill remain. The fragments of the fibula will .fall inwards toward 
the tibia, and the foot, unsupported by either its fibula or its internal 
ligaments, will incline perceptibly outwards. Xor can this be wholly 
prevented, in most cases, by any mechanical contrivance. Indeed, it 
would be easy to demonstrate, as I have often done to my pupils, that 
even Dupuytren's splint, usually employed in this accident, must fail 
of success in a great majority of cases, since the subsequent deformity 
is due less to the fracture of the fibula and its consequent displacement 
than to the loss of the internal ligaments, which loss nature can seldom 
fully repair. As further evidence of the correctness of this view, I 
will state that in three of the examples in which I have found the 
fractured fibula united and resting against the tibia, the motions of the 
ankle-joint have been completely recovered. 

If, however, it were true that a fracture and displacement of the 
fibula is the sole or essential cause of the subsequent deformity, it 
would still be found often impracticable to avoid the maiming, since 
it would still remain impossible to lift the broken ends from the tibia, 
against which, or in the direction toward which, they are so prone to 
fall. Inversion of the foot does not accomplish it, nor have I ever 
been able to make anything but the most trivial impression upon the 
upper end of the lower fragment by pressure upon the lower extremity 
of the fibula. 

I think too much confidence has been placed in the efficiency of 
"Dupuy trends splint." I believe, indeed, that this splint is a very 
appropriate means of support and retention after this accident ; but 
I doubt whether it is able to accomplish all that its illustrious inventor 
proposed. 

Treatment — Dupuytren's mode of dressing is essentially as fol- 
lows : 

A pad, or long junk, made of a piece of cotton cloth, stuffed with 
cotton batting, is constructed of sufficient length to extend from the 
condyles of the femur to a point just above the malleolus internus. 
This pad must be about five or six inches in width, and thicker by 
two or three inches at its lower than its upper end. This is to be laid 
upon the inside of the leg, with its base or thickest portion resting 
against the tibia just above the internal malleolus. Over this pad is 
to be placed a long firm splint, extending also from above the knee 
to three inches beyond the bottom of the foot. With a few turns of 
a roller the upper end of the splint will now be made fast to the knee, 
and with a second roller the lower end must be secured to the foot. 



480 



FRACTURES OF THE FIBULA. 



Fig. 220. 



The application of this last bandage requires, however, some care in its 
adjustment. Its purpose is simply to rotate the foot in- 
wards, while at the same time the tibia is pressed out- 
wards ; and to this end it must be applied in the form of 
a figure-of-8 over both splint and foot, embracing alter- 
nately the heel and the instep. In order to be effectual, 
it must be drawn pretty firmly, and no portion of the 
bandage must pass higher than the malleolus externus. 
In some surgical books I have seen this apparatus repre- 
sented with a roller embracing the whole length of the 
leg ; and in others it is represented as encircling the limb 
two or three inches above the malleolus; but it is evident 
that these modes of dressing must defeat the great object 
which Dupuytren had in view, namely, the throwing out 
of the upper end of the lower fragment. 

When the limb is thus dressed, the knee may be flexed 
and the leg laid upon its outside, supported by a pillow, 
or upon its inside, as in the accompanying engraving. 

If it is only a fracture of the external malleolus, or if 
the fracture has occurred in the middle or upper third of 
the bone, this treatment is no longer appropriate, and it 
will generally be found sufficient to place the limb at 
rest for a few days upon a suitable cushion or upon a pillow. 

Of late years I have not employed Dupuytren's splint quite so much 
as formerly, and especially because I have met with several examples of 
backward displacement of the foot following fractures of the fibula, 
which Dupuytren's splint is not competent to prevent or to remedy. 




Dupuytren 
splint incor- 
rectly applied 



Fig. 221. 




Dupuytren's splint as originally applied by himself. 



This subject will be considered more fully in connection with forward 
luxations of the tibia at its lower end ; but it is necessary to say here 
that this accident can be most certainly avoided by employing the 
plaster of Paris or starch dressing; taking care in applying the dressing 
to secure a thorough inversion of the toes and foot, the same as in case 
the limb were dressed with Dupuytren's splint. Care must be taken, 
also, not to press upon the limb much with the bandages above the 
malleolus externus. The same results may be attained, also, by a well- 
adjusted leather splint, or by two splints, which shall inclose the heel 
as well as the sides and front of the limb. 

It is scarcely necessary to say that, since after this accident anchy- 
losis is so frequent, early and unremitting attention should be given 
to the establishment of passive motion in the joint. Indeed, I cannot 



FEACTUKES OF THE TIBIA AND FIBULA. 481 

but think that a desire to accomplish the indications recognized and 
urged by Dupuytren has led to the neglect of the indication which 
ought to have been regarded as of equal, if not of the greatest, im- 
portance, namely, the prevention of contractions and adhesions around 
and between the joint surfaces. 

As a general rule, the dressings ought to be wholly laid aside by the 
end of the third or fourth week ; and although it may be well for a 
somewhat longer time to keep the foot turned in, by having it properly 
supported as it lies upon the pillow, yet after this date I regard the 
use of splints and bandages as only pernicious. 



CHAPTEE XXXII. 

FEACTUKES OF THE TIBIA AND FIBULA. 

Causes. — Probably four-fifths of these fractures are the results of 
direct blows or of crushing accidents, such as the kick of a horse, the 
passage of a loaded vehicle across the limb, the fall of heavy stones or 
timbers, etc. 

In an analysis of one hundred and eleven cases I find the bones 
broken in the upper third from a direct cause four times, and from an 
indirect cause once. In the middle third forty have been referred to a 
direct cause, and two to an indirect ; and in the lower third thirty -nine 
to a direct cause, and eighteen to an indirect. An observation which 
does not sustain the remark of Malgaigne, based upon his analysis of 
sixty-seven cases, that fractures of the upper third are produced by 
direct causes alone, those of the middle third much more frequently by 
indirect causes, and that those of the lower third are especially due to 
indirect causes. Direct causes produce a large majority of the frac- 
tures of the lower third, but the proportion is smaller than in the 
middle third. 

Of the indirect causes, falls upon the feet from a considerable height 
— as from a scaffolding, or from the top of a building — are by far the 
most common. Four times I have found the bones broken by mus- 
cular action alone, as in the following example : 

Mrs. W., of Buffalo, aged about twenty -five years, and weighing at 
this time nearly two hundred pounds, was descending her door-steps 
with an infant in her arms, when, the step being covered with ice, she 
slipped and fell, breaking her right leg just above the ankle. Mrs. W. 
says she felt and heard the bones snap before she touched the steps. 
Of this she is certain. 

We found the tibia broken obliquely, the fragments being quite 
movable, but not much, if at all, displaced. The limb was dressed 
with a carefully moulded and well-padded gutta-percha splint, and 
then laid in a pillow upon the bed. Mrs. W. experienced unusual 



482 FRACTURES OF THE TIBIA AND FIBULA. 

pain from the fracture for several days, for the relief of which we were 
compelled at times to permit her to inhale chloroform. She was of a 
nervous temperament, and had frequently resorted to chloroform before 
to relieve neuralgic pains. The limb became very much swollen, and 
remained so for a week or two. No extension was ever employed. 

Within the usual time the bones united in perfect apposition, and 
in about four months she was able to walk without any halt. 

Pathology, Symptoms, etc. — We have seen that fractures of both, 
bones through some part of the lower third are most frequent. Thus, 
of one hundred and fifty-five fractures, eleven belonged to the upper 
third, forty-five to the middle, and ninety-three to the lower. In six 
cases the two bones were broken in different divisions. It is probable 
that in this analysis some errors have occurred, and that in a larger 
proportion than here stated the two bones have given way at opposite 
extremities, since it is often difficult, and sometimes quite impossible, 
to determine precisely where the fibula is broken; but the analysis is 
sufficiently correct to illustrate the much greater frequency of fractures 
of the lower third, and also the fact that the two bones generally break 
nearly on the same level ; usually the point of fracture in the tibia is 
between two and three inches above the joint. 

In an -examination of twenty museum specimens, I have found both 
bones broken at the same point, or within two or three inches of the 
same point, sixteen times, and at extreme points four times ; and in 
these last examples the tibia has always been broken in the lower 
third, while the fibula has been broken in the upper third. 

In seventeen of the fractures mentioned as belonging to the lower 
third only the malleolus of the tibia was broken, while the fibula was 
broken two or three inches above its lower end. Some of these were, 
perhaps, examples of dislocation of the ankle. 

I have seldom seen a transverse fracture of the tibia, except in its 
lower or upper extremity, in the expanded portions of the bone; and 
even in those examples which we are accustomed to call transverse, 
because they are sufficiently so to prevent any sliding or overlapping 
of the fragments, there has existed, generally, a marked inclination of 
the line of fracture in one direction or another. 

The examples of fracture produced by muscular action have, without 
an exception, occurred in adults. Three of them were in the lower 
third of the leg, and one in the middle third. I think they were all 
of them nearly transverse, since they never became much, if at all, 
displaced. 

Most of the fractures of the tibia produced by falls upon the feet 
are very oblique, and the direction of the fracture is generally down- 
wards, forwards, and inwards ; but I have found almost every con- 
ceivable variation from this general rule. 

The fracture in the fibula is even more constantly oblique than the 
fracture in the tibia; but this is a point of very little practical conse- 
quence, and one which we can seldom determine positively, unless one 
of the fractured ends protrudes through the flesh. 

Compound and comminuted fractures are more frequent here than 
in any other of the bones of the body. My tables, which have rejected 



FRACTURES OF THE TIBIA AND FIBULA. 483 

all fractures demanding immediate amputation, most of which are com- 
pound, do not for this reason give a just idea of their proportion to 
simple fractures, yet even in these tables, of one hundred and seventy- 
two fractures, sixty -two were compound, and also, generally, more or 
less comminuted. Of eighty cases reported by W. "VV. Morland, of 
Boston, from the Massachusetts General Hospital, and in which the 
character of the accident is recorded, thirty-nine were compound. 1 

The symptoms indicating a fracture of both bones of the leg are the 
same which are usually present in other fractures, namely, mobility, 
crepitus, shortening of the limb, distortion, swelling, etc. Generally 

Fig. 222. 




Compound and comminuted fracture of the leg. 

the lower end of the upper fragment projects in front, and can be seen 
or felt ; but in some instances the swelling follows so rapidly that it is 
impossible to feel distinctly the point of fracture, and its existence can 
only be determined by the crepitus, mobility, and shortening of the 
limb, or, perhaps, by the marked deformity or deviation from the 
natural axis. 

The shortening, where it exists at all, varies at the first from a line 
or two to a half or three-quarters of an inch. Generally, it is about 
half an inch. 

Prognosis. — The average period of perfect union in twenty-nine 
cases, including those in which union was delayed by extraordinary 
causes beyond the usual time, was forty days. The general average, 
under ordinary circumstances, may be stated at about thirty days. 

Union has been delayed in seven cases, five of which were simple 
fractures, and two were compound. The longest period was seventeen 
weeks. 

F. C. T., of Erie Co., N. Y., set. 35, had an oblique, simple fracture 
of both bones, in the upper third, caused by jumping from a buggy, in 
June, 1852. 

The limb was dressed with lateral splints, compresses, and bandages, 
and laid upon a pillow. 

Eight weeks after the fracture had occurred, the gentlemen in at- 

1 Transac. of Mass. Med. Soc. for 1840 ; Fractures, by A. L. Pierson. 



484 FRACTURES OF THE TIBIA AND FIBULA. 

tendance wished me to see the limb with them. I found Mr. T. still 
in bed, and the fragments not at all united. 

Mr. T. had enjoyed average health heretofore, but he was never 
very robust. When I was called to see him he looked pale ; his skin 
was cold and moist, pulse 120, and appetite poor. The broken leg 
and foot were greatly swollen. The swelling was oedematous. Con- 
siderable excoriations existed on the back of the leg. The fragments 
were quite movable, and were overlapped three-quarters of an inch. 

We agreed that the patient ought, as soon as possible, to be got out 
of bed, so as to enable him to recover his strength, which had sadly 
declined. To this end, a gutta-percha splint was made to fit accurately 
the whole length of the leg ; and, having attached a large number of 
tapes, it was to be secured upon the limb. Several times each day it 
was to be removed, and the limb bathed with brandy and water. 
Gradually, also, the limb was to be brought down to the floor, and the 
patient be made to sit up, and, as soon as possible, he was to walk with 
crutches, or to ride. 

Nov. 4th, 1852, Mr. T. visited me at my house. The directions had 
been followed implicitly. About two weeks after my visit he rode 
out, and in about nine weeks, or seventeen weeks from the time of 
the fracture, the bones were found united. His health and strength 
were quite restored, and the limb was no longer oedematous. It was 
found to be straight, or with only a slight projection of the upper 
fragment in front of the lower, and shortened three-quarters of an inch. 

A gentleman, set. 33, from Bergen, N. Y., was struck by a billet of 
wood on the 3d of August, 1856, breaking his left leg nearly trans- 
versely, three and a half inches above the joint. The fracture was 
simple. A surgeon was called immediately, who applied bandages and 
side-splints, and then laid the limb over a double-inclined plane. At 
the end of six weeks the dressings were removed, but the bones had 
not united. Four years after the accident, this gentleman consulted 
me. I found him in good health, but no union had yet taken place. 
This is the only example, except where amputation or death inter- 
posed, in which the union has been so long delayed as to entitle it to 
be considered as a case of non-union. My own observation would, 
therefore, incline me to think that, while non-union is a rare event in 
fractures of the leg, delayed union is more frequent than in most other 
fractures. 

It has once occurred to me to see a complete non-union of the fibula 
after a period of several years, while the tibia had united well. This 
circumstance occasioned no inconvenience to the patient, and was not 
known to him until I had made the discovery. 

A little more than one-half of those cases in which an accurate 
note of the result has been made, have been found to be more or less 
shortened by overlapping, namely, sixty-one cases out of one hundred 
and ten. The greatest amount of shortening in any one case has been 
one inch and a half; and the average shortening of the sixty-one cases 
has been half an inch and a fraction over. This analysis includes both 
simple and compound fractures ; but a pretty large proportion of the 



FRACTURES OF THE TIBIA AND FIBULA. 485 

simple fractures have also been found shortened, as in the following 
extreme illustration : 

John Granger, of England, set. 43, was tripped by a stone while 
walking, breaking his right leg through its lower third. Fracture 
simple and oblique. It was treated by a surgeon, of Hungerford, Eng- 
land, who employed only side-splints. 

Two years after, I found the leg shortened one inch, the upper frag- 
ment riding upon the front and inner side of the lower. 

Generally, when a shortening has occurred, I have found the upper 
fragment in front of the lower, and oftener a little more upon the inner 
than upon the outer side. 

The deviation from the natural axis of the limb has been noticed by 
me in a good many instances. Seven times the lower part of the limb 
has fallen backwards, and five times it has, in a degree much less 
marked, inclined inwards. Once I have seen it inclined outwards, and 
twice forwards. 

Ulcers upon the back of the heel, seen by me seven times, as a result 
of undue pressure upon this part, have, however, been presented but 
three times in cases of simple fractures. 

It is not very unusual to find, also, over the exact point of fracture, 
and after the lapse of several months, or even years, an ulcer, or sinus, 
which is due sometimes to the presence of a small fragment of bone 
which has remained in the wound from the time of the accident, or to 
a thin scale which has subsequently exfoliated. In other cases it is 
due to the prominence of the salient angle when the lower part of the 
limb inclines considerably backwards, and in still other cases, no doubt, 
to the general dyscrasy of the system, and to the same causes which 
produce chronic ulcers in the lower extremities where only the skin 
has been originally injured. I have reported elsewhere examples of 
this complication existing after five months, two and three years, 1 and 
in the remarkable case which I shall now briefly relate an ulcer existed 
at the end of twenty- three years. 

Thurstone Carpenter, when four years old, received an injury, break- 
ing both bones of one of his legs near its middle. The fracture was 
compound. It was dressed and treated by an excellent surgeon, then 
residing in Buifalo, but long since dead. 

Twenty-three years after the accident, Mr. Carpenter called upon 
me on account of a paralysis of his lower extremities, which had re- 
cently occurred. He stated that from the time of the fracture until 
within about one year an open ulcer had existed over the seat of frac- 
ture, and that soon after it had closed over completely he began to lose 
the use of his limbs. During the time it was open, small scales of 
bone have frequently been thrown off. The limb is half an inch 
shorter than the other, but straight. 

A gentleman residing 'in Quincy, Chautauque Co., X. Y., had his 
tibia and fibula broken near the ankle-joint in the year 1844, by the 
passage of a carriage-wheel across his limb. The skin was a good 
deal lacerated. The wounds, however, healed kindly, and the broken 

1 Trans. Amer. Med. Assoc. Report on Deformities after Fracture.. 



486 FRACTURES OF THE TIBIA AND FIBULA. 

bones united in the usual time without any apparent deformity; but 
the limb continued swollen and painful, until finally suppuration took 
place. After twelve years of great suffering, I amputated the leg near 
its middle, from which time he made a speedy recovery. I found the 
lower end of the tibia inflamed, softened, and expanded, and contain- 
ing in its interior about three ounces of pus, but no sequestrum. 

Anchylosis of the knee or ankle-joint may follow as a result of the 
accident or of improper treatment ; and at one or both of these joints 
I have found more or less anchylosis at the end of nine months, one 
year, six years, twenty-five, thirty, and forty years. Generally, how- 
ever, it disappears in a few weeks, and seldom remains to any consid- 
erable extent in the knee-joint after the dressings have been removed 
two or three weeks; but an Irishman called upon me in 1853, wdiose 
leg had been broken about three inches below the knee-joint six years 
before. It was a simple fracture. A surgeon in Ireland had treated 
the case. I found the limb shortened one inch and a half, the frag- 
ments being overlapped and displaced backwards at the point of frac- 
ture. The knee was also partly anchylosed. I could not learn what 
the treatment had been. 

In other cases, where no permanent anchylosis has followed, the 
ankle-joint has been occasionally painful, and subject to swellings, 
after the lapse of many years. 

After all that has been said as to the occasionally serious nature of 
the consequences of these accidents, as shown in the shortening of the 
limbs, in their deviations from their natural axes, in the stiff ankles, 
ulcers, and abscesses, it must be still admitted that in another point of 
view these results are not extraordinary, and may hereafter continue 
to be fairly anticipated in a certain proportion of cases, even under 
the best management ; since it must be understood that more fractures 
of the leg are attended with serious complications than of any other 
limb; and that while many produce death rapidly from the severity 
of the shock, and very many are condemned at once to amputation, a 
large number of those which are saved have been in that condition 
which has rendered the application of bandages or splints impossible 
for many days. Indeed, not a few of these crooked limbs may still be 
presented as real triumphs of the art of surgery, inasmuch as by con- 
summate skill alone have they been saved. 

Treatment. — It is wholly impossible in a class of fractures which 
present so great a variety in regard to form, seat, and complications, 
to establish any universal system of practice; nevertheless it is possible 
to declare certain general principles in reference to a few w T ell-recog- 
nized classes or varieties : and I shall deem it especially important to 
record my disapproval of certain plans of treatment which have from 
time to time been suggested and adopted. 

It is seldom that I have found it necessary or useful to apply any 
bandages directly to the skin, whatever form of apparatus has been 
employed, but in certain cases of compound fractures, where dressings 
have been applied which needed support and protection, a bandage 
has been of service. The roller, unless the patient is a child, whose 
limb can be easily lifted and managed, is always objectionable ; but 



FRACTURES OF THE TIBIA AND FIBULA. 487 

the many-tailed bandage, made of narrow strips of cloth, laid upon 
each other, as we have already described in our general remarks upon 
bandages, etc., is occasionally useful. 

Having made these preparations, we proceed to flex the leg to a 
right angle with the thigh, and by the hands make extension and 
counter-extension as much as the patient will bear, or as much as may 
be necessary to restore the fragments to place, in case this restoration 
is found to be practicable. If the fracture is compound, and the point 
of bone protrudes through the skin, it is often difficult to replace it. 
That is, we are unable to overcome the action of the muscles sufficiently 
to make the limb of its natural length, and for this reason, mainly, we 
are unable to get the point of bone beneath the skin. If we cannot 
then "set" the bone, or bring the ends into apposition, and this will 
be the fact pretty often, we still have no apology generally for leaving 
the bone outside of the skin. First, an attempt must be made to 
accomplish this reduction by pulling aside the skin with the fingers, 
or with a blunt hook. This simple procedure has often succeeded 
with me in a moment, when others have been trying in vain to accom- 
plish the same end by pulling upon the limb. If this fails, then the 
skin should be cut sufficiently to allow the bone to retire, or if the 
point is sharp, and especially if it is stripped of its periosteum, it may 
be sawn or cut off. Resecting thus the end of an oblique fragment 
does not generally affect in any degree the length of the limb, or inter- 
fere with a prompt and perfect cure, but, on the contrary, it often is 
advantageous in every point of view. 

We are now prepared to apply the splints. Before, however, con- 
sidering the character and form of the splints to be applied, it seems 
proper to call attention again to the danger of ligation of the limb 
from the tightness of the bandages, and especially from the use of a 
bandage or roller placed beneath the splints and directly against the 
skin. 

The larger size and irregular form of the bones of the leg, the small 
amount of muscular tissue covering them, especially near the articula- 
tions, the severity of the injuries to which they are liable, with their 
remoteness from the centre of circulation — these circumstances alto- 
gether, render them exceedingly exposed to injury from the too great 
or unequal pressure of splints or of bandages; and it has often occurred 
to myself, as it has to Dr. Norris, whose remarks upon this point we 
have already quoted, to find the skin vesicated, or even ulcerated and 
sloughing, when the patients are first admitted to the hospital; a con- 
dition which, in nine cases out of ten, is due to the maladjustment of 
the splints, or to the tightness of the bandages. 

If bandages are used under the splints, and next to the skin, they 
must be applied very moderately tight, and loosened or cut as the 
swelling augments ; and, from the first day of treatment to the last, 
the surgeon must be careful to loosen or tighten the dressings when 
the swelling increases or subsides, just as the prudent boatman trims 
his sails to the rising and falling breeze. 

Dr. Krackowitzer presented to the Xew York Pathological Society, 
June 10, 1863, a leg which he had amputated for gangrene occasioned 



488 FRACTURES O.F THE TIBIA AND FIBULA. 

by tight bandages. A boy, five years old, sustained an injury of the 
ankle-joint, which his medical attendant pronounced a fracture of the 
fibula, and for which he applied only a tight bandage. The child 
suffered a good deal after the bandage was applied, and the following 
morning the toes were blue, but the doctor paid no attention to this 
circumstance. The pain subsided on the third day, and on the fourth 
the bandages were removed, and the limb found to be gangrenous. 

The specimen showed that the fibula was not broken, but that there 
was a fissure or crack in the lower part of the shaft of the tibia. 1 

The following case, which has been communicated to me by Dr. 
Fuller, of Wyoming, N. Y., with permission to make such use of it 
as I choose, is sufficiently pertinent for the instruction of others, and 
deserves a public record : 

A man, set. 71, fell from a tree, striking upon his foot, August 27, 
1855, producing a backward dislocation of both the tibia and fibula 
upon the os calcis, and also a fracture of both bones of the leg a few 
inches above the ankle. 

An empiric took charge of this unfortunate man, and immediately 
applied lateral splints and a firm roller from the toes to the knee. 
Notwithstanding the remonstrances and prayers of the patient to have 
the bandage loosened, it w T as kept on until the ninth day, when the 
doctor cut the bandage upon the top of the foot, and it was found 
vesicated. Ignorant, however, as to the cause of this vesication, and 
of the danger which it threatened, he omitted to loosen the remainder 
of the bandages, and the limb w T as left in this condition until the 
twenty-third day, when Dr. Fuller being called, and having removed 
all the dressings, found the integuments covering the whole foot dead 
and dried down to the bones. The dislocations had not been reduced. 
Soon after this the limb became oedematous, and on the 27th of October 
the leg was amputated by Dr. Barrett, of Le Roy, from which time 
the patient recovered rapidly. 

The fragments being adjusted, two lateral splints of leather, long 
enough to extend from near the knee-joint to the metatarso-phalangeal 
articulations, and wide enough to nearly encircle the limb, are moulded 
to the limb on each side, and secured in place by successive turns of 
the roller. When the skin is delicate or tender, these should be un- 
derlaid with a thin sheet of cotton wadding or of patent lint. A soft 
woollen cloth may answer the purpose equally well. A rack is then 
placed over the limb, such as will be seen figured for the suspension 
of the limb when dressed with plaster of Paris, and from this the leg 
is suspended. The objects to be attained by the suspension are three- 
fold : first, to avoid the danger of pressure upon the heel, and conse- 
quent ulceration ; second, to prevent that driving down of the upper 
fragment upon the lower which constantly ensues when the foot rests 
upon the bed or in a box which is immovable ; third, to obviate 
movement of the fragments upon each other when the patient sits up 
or lies down in bed. This movement, I observe, is peculiar. It is not 
simply a motion of the fragments upon each other, as upon a pivot at 

1 Krackowilzer, Amer. Med. Times, Nov. 7, 1863. 



FRACTURES OF THE TIBIA AND FIBULA. 489 

the point of fracture, which motion seldom interferes materially with 
consolidation, but it is a rising and falling of the upper fragment, or 
a motion to and from of the fragments, and also a riding motion ; 
either of which latter movements necessarily delays or defeats bony 
union. It is because these motions are generally permitted to occur in 
the usual modes of dressing these fractures, more than for any other 
reasons, that union is so often delayed in the case of these bones. In 
my own practice, when this plan of suspension is enforced, delay seldom 
occurs, but nothing is more common than for me to meet with it when 
other surgeons have had charge of the limb, and the suspension has 
been omitted. 

In suspending the limb, it is only necessary that the leg should float 
clear of the bed ; and I think it worth while to say that when leather 
is used for splints, a broad oval piece of leather or of some other firm 
material should receive the limb in suspension, rather than pieces of 
bandage, which soon become cords, and press unequally. To the sides 
of these oval pieces bauds are attached, and their ends tied over the 
top of the rack. One must be placed under the knee and one under 
the ankle. 

If the fracture is above the middle of the leg, complete quietude of 
the fragments can only be obtained by carrying the splints and the 
bandages above the knee. 

I have already, in my remarks on the treatment of fractures in 
general, declared my acceptance of the so-called "immovable appa- 
ratus" in the treatment of certain fractures of the leg below the knee, 
and especially of the plaster of Paris dressings. In hospital practice, 
where these dressings can be applied by experts, and where the limb 
can be watched daily and hourly, most or all of the dangers incident 
to this form of dressing may be avoided ; but even here I have occa- 
sionally seen, from a little too much delay in opening the dressings, 
serious trouble ensue. Its most devoted advocates, Seutin, A T elpeau, 
and others, have never denied the necessity of caution in its use. To- 
day I hear of a surgeon in a neighboring State who has been prose- 
cuted for damages in consequence of the death of the limb, caused, as 
is alleged, by this form of dressing. On the other hand, when applied 
judiciously, even immediately after the receipt of the injury, and 
when carefully watched and opened freely on the first notice of danger, 
it has, in my wards, and in the hands of my excellent house surgeons, 
often served its purpose more completely than any other apparatus or 
splints I have ever seen employed. It has steadied and supported all 
parts of the limb more completely, and permitted it to be handled 
more freely, than anything else could do. In simple fractures patients 
have been permitted to walk about upon crutches after the third or 
fourth day, and generally no harm has resulted. In one case, how- 
ever, I believe this liberty caused a serious delay in the union ; and in 
another an abscess resulted, which would have been avoided if he had 
remained in bed. 

But it is in the management of compound fractures of the leg that 
I have of late seen the greatest advantage in this mode of dressing; 
and it was in precisely these cases that I formerly believed the immova- 

32 



490 FRACTURES OF THE TIBIA AND FIBULA. 

ble apparatus most objectionable. I do not wish to retract anything 
I have heretofore said as to its dangers, but I have not until lately 
fully appreciated to what a degree these dangers might be overcome by 
skill and attention. 

The following careful description of the proper mode of applying 
plaster of Paris bandages in fractures of the leg has been prepared at 
my request by Dr. S. B. St. John, late house surgeon to Bellevue 
Hospital. His large experience and his habits of accurate observation 
render his statements peculiarly trustworthy. 

"The materials necessary are, blanket, or cotton wadding, blanket 
being preferable, and plaster of Paris bandages, which are prepared by 
rubbing dry plaster into the meshes of a bandage of coarse texture, 
and rolling it up so as to make it convenient of application. (These 
may be kept ready for use in tin cans.) The bones having been placed 
in position, the leg is placed upon the blanket, which is cut and folded 
neatly around it,, and secured by a few pins. The blanket should ex- 
tend from the base of the toes to the knee, or in case of fracture above 
the middle, or of compound fracture at any point, a few inches above 
the knee. The plaster bandages should then be immersed in hot 
water, to which a little salt has been added to hasten the setting, and 
while in the water they may be gently kneaded to insure moistening 
of every part. In about three minutes, or when bubbles of air cease 
to rise from them, they will be ready for use, and should be taken out 
as they are wanted, and gently squeezed to get rid of superfluous 
water. They are then to be applied after the fashion of an ordinary 
bandage, over the blanket, with just sufficient firmness to insure a 
complete fit. If, at any revolution of the bandage, the plaster is seen 
to be dry, it should be moistened by dipping the hand in water and 
rubbing it over the dry surface. Extra turns of the bandage should 
be taken at the places where it is necessary to secure extra strength to 
the splint. Three or four bandages (six yards long) are usually suffi- 
cient to make a firm splint. The splint will usually be sufficiently 
pliable just after its application to allow of rectification of any faulty 
position which may have occurred during its application. It should 
then be kept in shape by the pressure of the hands until it hardens, 
which will be in from ten to thirty minutes, according to the freshness 
of the plaster and texture of the bandages used. If, for any reason, 
it is desirable to cut the splint so as to admit of its removal, or to cut 
a fenestra through which to observe any part, this may best be done 
before the plaster becomes perfectly dry, say in from two to five hours 
after its application, depending upon the quality and freshness of the 
plaster. It will then cut like hard cheese, and a stout sharp knife 
should be used. In splitting a splint anteriorly, it is convenient at the 
same time to take out a piece about an inch wide, by making two 
parallel cuts one inch apart, one on either side of the median line, ex- 
tending nearly through to the blanket, and then by raising the strip at 
the upper edge, and cutting on either side alternately, the section may 
be completed, and the central slip removed without danger of cutting 
through the blanket and wounding the patient. The blanket may 
then be cut with scissors and the splint sprung off to examine the limb, 



FRACTURES OF THE TIBIA AND FIBULA. 



491 



if necessary. When replaced, a bandage should be applied over it. 
If it should be necessary to cut a splint which has already become 
dry, and cuts with great difficulty, it may be softened with hot water, 
applied by a sponge in the track of the proposed section for ten or 
fifteen minutes. 

" If it is necessary to cut such a large fenestra that only a small strip 
of the splint would be left connecting its upper and lower portions, it 
is better to adopt a different plan of application. For this it is neces- 
sary to have a solution of plaster of Paris in water of the consistency 
of cream. A piece of blanket is then cut long enough to reach from 
the toes to the top of the proposed splint, and about fifteen inches wide. 
This is to be thoroughly soaked in the solution, and folded several 
times so as to be about two or three inches wide when folded. This is 
to be applied along that part of the limb which it is not necessary to 
keep under observation (if convenient, along its posterior aspect), and 
it is then to be secured in position by circular turns of the plaster 
bandage above and below the portion to be left exposed. Whenever a 
plaster apparatus extends above the knee, and it is proposed to sling 
the leg from a cradle, the leg should be flexed slightly upon the thigh, 
so that it may be swung horizontally. Any portion of a plaster splint 
exposed to the moisture of discharges or of water used in dressing, 
should be carefully protected by oil silk and cotton wadding. 

"In cases where not much swelling is anticipated, blanket is prefer- 
able to cotton wadding, as an elastic medium between the splint and 
skin, because it is of more even thickness and retains its place better 
when the splint is removed, but cotton answers better when much 
swelling is anticipated, as being more elastic." 

The accompanying illustration has also been made for me by Dr. 
St. John, and furnishes a faithful picture of one of the many similar 
cases which have been under treatment by this method at Bellevue 
Hospital. 

Fig. 223. 




Plaster of Paris dressing, and suspension. 



Dr. George A. Van Wagenen, while acting as house surgeon at 
Bellevue, devised a most ingenious, simple, and effective apparatus 
for suspending the limb, which will be found illustrated in the ac- 
companying woodcut. 

" It consists of an elbow T of wood projecting over the foot of the 
bed, from which the leg is suspended by two pieces of rubber tubing ; 



492 



FRACTURES OF THE TIBIA AND FIBULA. 



,, holding tne rings 

■this last being far the most import- 

side. Motion on these rollers is 



one above the ankle, the other just below the knee. The tubes have 

common grooved iron pulleys or wheels at each end : those above, 

rolling on a large iron wire to allow motion toward the head or foot of 

the bed ; those below, at right angles to the others, holding the 

of rope in which the leg rotates 

ant, allowing patient to turn on either 

accomplished with so little resistance that there is no pain. 

"The upright of the elbow to go at the foot of the bed should be 
long enough to rest on the floor, or any convenient post of the bedstead, 
and project about two feet above the level of the mattress, — the hori- 
zontal piece long enough to reach nearly to the knee; pine } by 2 inches 
is heavy enough. The angle made by these pieces is braced, and a 
strap of hoop-iron outside makes it very strong. In the horizontal 
piece two slots are cut wide enough to allow the iron pulleys to pass 
through, and of sufficient length to allow the patient to draw himself 
up and down in bed. A J inch iron wire passes the whole length of 
this piece above the slots, steadied by small staples, so that it may be 

withdrawn. On this the upper pulleys run. The wire shields i 1 

above these slots are to prevent the bed-clothes from resting upon the 
rollers. 

" The pulleys or wheels are fastened in the rubber tubes by making 
a few turns of copper wire around the iron screw of the pulley. This 
is pushed into the tube and bound outside with fine wire. 



Fig. 224. 




Van Wagenen's suspension apparatus. 

"Rings of rope large enough to pass over the foot are then put 
through the lower pulleys. If these rings open, or the foot is slipped 
out of them, the leg is taken down without any of the apparatus about 
it, and the large wire may be withdrawn and the leg lowered, with the 
pulleys and rings still attached." 1 

There are a few cases in which a very much better position of the 
fragments can be secured by placing the patient under the influence of 



1 Van Wagenen, Med. Kecord, April 1, 1873. 



FRACTURES OF THE TIBIA AND FIBULA. 



493 



an anesthetic, and by applying the dressing daring complete anaesthe- 
sia. But the surgeon needs to be warned of two things in this connec- 
tion : first, that just as much harm can be done to the soft parts by 
violent wrenching and pushing when he is insensible as when he is 
fully conscious ; second, that while the patient is passing under the 
influence of an anaesthetic he is liable to violent muscular spasms, 
which may do serious injury. 

In such few cases as demand or warrant a resort to permanent exten- 
sion and counter-extension, a double-inclined plane furnishes a conve- 
nient mode for its accomplishment; but it is only occasionally that, in 
fractures of the leg, permanent extension and counter-extension can be 
employed ; an assertion which, however much it may excite surprise, 
experience will prove true. If the fracture is near the middle of the 
leg, quite remote from the points upon which the appliances for exten- 
sion, etc., are to be made fast, and the inflammation is moderate, some- 
thing may be done in this way; but when the point of fracture ap- 
proaches the ankle-joint, as it actually does in a great majority of cases, 
a gaiter, made of any material whatever, if it has sufficient firmness to 
overcome completely the action of the muscles, will inevitably cause 
congestion and swelling, accompanied sooner or later with great pain 
and with ulcerations, and simply because the extension is made directly 
upon parts already tender and inflamed from the accident itself; and 
when we add to this complete and violent ligation of the limb near the 
seat of fracture, a similar ligation of the limb just below the knee, for 
the purpose of making counter-extension, as is done in what is known 
among American surgeons as "Hutchinson's splint/' 1 we are prepared 



Fig. 225. 




k*i 



James Hutchinson's splint, for extension, etc., in fractures of the leg. (From Gibson.) 

to understand how the worst consequences may ensue. I have once 
seen, when this abominable apparatus had been used, a complete ring 
of ulceration below the knee, and another as complete around the foot 
and ankle. The limb was twice girdled, and yet the surgeon thought 
he was performing a duty for the omission of which he would scarcely 
have been regarded as excusable. 



1 Elements of Surgery, by John Syng Dorsey, vol. i, p. 181. Philadelphia, 1813. 



494 



FRACTURES OF THE TIBIA AND FIBULA. 



Jarvis's adjuster, a still more mischievous, inasmuch as it is a more 
powerful instrument, operating in a similar manner, has been produc- 
tive of like consequences ; but Jarvis's adjuster is liable to the addi- 
tional objection that by its great weight it drags off the limb, turning 
the toes outwards, an objection which no care or diligence can generally 
overcome. 

I could wish that neither of these appliances would ever again be 
impressed into the service of broken legs. 

Neill, of Philadelphia, and others have sought to overcome some of 
the difficulties in the way of making extension in fractures of the legs, 

Fig. 226. 




John Neill's apparatus for fractures of the leg requiring extension and counter-extension. 

by substituting adhesive plaster for the usual extending or counter- 
extending bands. 

Says Dr. Neill : " For simple fractures of both bones of the leg, at- 
tended with shortening and deformity not easily overcome, the limb 
should be placed in a long fracture-box with sides extending as high 
as the middle of the thigh, and a pillow should be used for compresses. 

" The counter-extension is made by strips of adhesive plaster, one 
inch and a half in breadth, secured on each side of the leg below the 

Fig. 227. 




John Neill's apparatus for compound fractures of the leg. 

knee, and above the seat of fracture by narrower strips of plaster 
applied circularly. The end of the counter-extending strips may then 
be secured to holes in the upper end of the sides of the fracture-box, 
by which the line of the counter-extension is rendered nearly par'allel 
with the limb. 

" The extension is also to be made by adhesive strips, in a mode 
which is now well known and understood. The ends of the extending 
bands may be fastened to the foot-board of the box." 1 



1 Philadelphia Med. Exam., vol. xi, p. 580, 1855. 



FRACTURES OF THE TIBIA AND FIBULA. 



495 



Dr. Neill further remarks : " In compound fractures of the leg, 
shortening and deformity are often difficult to overcome, as is well 
known to experienced surgeons. In such cases we may wish to dress 
the wounded soft parts, and, at the same time, maintain a certain 
amount of extension and counter-extension. 

" This can be readily accomplished by having the sides of the frac- 
ture-box sawed in two parts at the knee, so that the sides of the box 
above the knee, from the upper ends of which the counter-extension is 
made, need not be disturbed during the dressing, while that portion of 
the side of the box corresponding to the leg may be opened at pleasure, 
without diminishing the tension of the extending or counter-extending 
bands." 

In compound fractures of the leg, Dr. Gilbert recommends a modi- 
fication of the common fracture-box. In this apparatus the foot-board 

Fig. 228. 




Gilbert's box for compound fractures of the leg. 
1. The four counter-extending adhesive strips, as if encircling the knee and upper part of leg. 
2. The two extending adhesive strips crossing at the bottom of the foot, ready to he applied to The 
foot. 3. Tourniquet. 

is omitted, and a block for the reception of the frame of the tourniquet 
is substituted. Each side of the box consists of three separate seg- 
ments. Of these the upper and lower are permanently screwed to the 
bottom -board, and the central one is attached by hinges. By this 
arrangement there is full access to the wound, which may be dressed 
from day to day without disturbing the extension and counter-exten- 
sion, maintained by the permanently attached upper and lower seg- 
ments. 

The following woodcuts are intended to illustrate an apparatus 
invented by R. O. Crandall, for the purpose of making permanent 



Fig. 229. 




Section of Crandall's apparatus, applied to the limb ; showing adhesive plaster counter-extending 
bands and gaiter for extension, etc. 



496 



FRACTURES OF THE TIBIA AND FIBULA. 



extension. The extension is represented as being made by a gaiter, but 
Dr. Crandall leaves it to the choice of the surgeon whether he shall 
employ the gaiter or adhesive strips. 1 

Without intending to deny to these contrivances for permanent ex- 
tension much ingenuity and considerable practical value, I am far from 

Fig. 230. 




Crandall's apparatus complete. The counter-extending straps are passed over a block of wood sup- 
ported above the knee, to prevent their pressure upon the sides of the knee. 

conceding that they will be found capable of overcoming the action of 
the muscles where the ends of the fragments do not support each other. 
Their mode of action is such that they can scarcely do more than to 
steady the limb, and if they operate upon the fragments at all in the 

Fig. 231. 




Posterior view of the lower portion of Crandall's apparatus. 

direction of their axes, it must be only in the most inconsiderable de- 
gree. The adhesive plasters are substituted for the circular knee-bands 
and the gaiters, with a view to avoid ligation; but in order to do this 
they must not encircle the limb, but only be laid parallel to its long axis. 
The leg of an adult, or that portion to which the adhesive plasters can 
be applied, supposing the fracture to be exactly at the centre, may be 
sixteen inches, that is, eight inches for extension and eight for counter- 
extension; but when we employ the same means for extension in frac- 
tures of the thigh, we find it necessary to apply the strips over the 
whole of these sixteen inches, the entire length of the leg, or they will 
not hold. It will be apparent also that we cannot use even the eight 
inches which we have, for the purpose of argument, allowed these 
gentlemen in fractures of the leg. There must be at least a space of 
eight inches between the ends of the two opposing strips in order that 
they may operate at all upon the fragments; indeed, I do not believe 
that even then their influence would reach beyond the skin to which 



1 Crandall, Phil. Med. Journ., vol iv, p 193, Jan. 1856; also Transac. of Med. 
Assoc, of Southern and Central New York, 1855, pp. 81, 82. 



FRACTURES OF THE TIBIA AND FIBULA. 497 

they were directly applied; but if a space of eight inches is left, only 
four remain for the strips at either end; and this is an amount of surface 
wholly insufficient for our purpose. What, then, shall we do when the 
fracture is near one of the extremities of the bone ? These gentlemen 
seem to have forgotten, moreover, that the whole leg is tender, and that 
the skin easily vesicates. In short, they have not seen the many points 
of difference between the application of these means in fractures of the 
thigh and leg, and which, while they allow us to accomplish all that 
we could desire with the one, are of little or no use in the other. We 
shall then always come to the same conclusion ; whatever means we may 
employ to make permanent extension in fractures of the leg, we must 
either fail to accomplish all that w 7 e desire, or incur the hazards incident 
to complete and firm ligation of the limb; and if the preference is 
given to any form of apparatus to accomplish these ends, it must be to 
some form of the double-inclined plane, by which we may at least avoid 
ligation in the upper part of the limb, the counter-extension being made 
against the under surface of the thigh while it is resting upon the thigh- 
piece; or to one of the long straight thigh-splints, which will enable 
us to make the counter-extension from the thigh and perineum. 

If a double-inclined plane is used, I prefer either a plain apparatus, 
such as we have already described as in use for fractures of the thigh, 
constructed of boards, joined together by hinges opposite the knee, and 
with an upright footboard, upon which a carefully arranged and thick 
cushion has been placed, or the more elegant double-inclined plane of 
Liston. 

In using Liston's apparatus, it must not be inferred that the knee is 
always to be bent. The apparatus is designed to be used occasionally 
as a straight splint; and there will be found many cases of fractures of 
the legs in which the straight position will be most suitable: this is 
especially true of such fractures as, occurring just below the knee-joint, 
have the line of fracture directed obliquely downwards and forwards. 
But there are many compound fractures which demand the same ex- 

Fig. 232. 




Liston's double-inclined plane ; applied to the leg in a case of compound fracture. (From Miller.) 

tended position; and in nearly all cases where this form of apparatus 
is used as a double-inclined plane, the lower end of the splint should 
be elevated so that the heel shall not be much below the level of the 
knee. 

Bauer's wire splints, used also for side-splints, when they are formed 



498 



FRACTURES OF THE TIBIA AND FIBULA. 



to fit the limb accurately, possess some advantages which must recom- 
mend them to the attention of surgeons ; but neither these splints nor 
any others, however accurately fitted, ought to be applied directly to 



Fig. 233. 




Louis Bauer's wire splints for the leg. 



the naked skin. They require always the interposition of a well- 
padded lining. 

Boxes are rarely useful except in certain compound fractures. They 
are heavy and awkward machines, which prevent the patient from 
moving readily in bed ; or which, being fixed, if he does move, allow 
the upper fragment only to descend, or to move upon the lower as a 



Fig. 234. 




Swing box or " cradle." (From Skey.) 



fixed point. If used at all, they ought generally to be suspended, or 
made to move on a suspended railway. But, however, they are ar- 
ranged, the limb is a great part of the time concealed from sight, and 
the surgeon is prevented from making use of such means to rectify 



Bauer, Buffalo Medical Journal, April, 1857, vol. xii. 



FRACTURES OF THE TIBIA AND FIBULA. 



499 



deviations in the line of the bone as he would probably have otherwise 
employed. 

The swing invented by James Salter, of London, is constructed so 
as to allow not only a lateral motion, but also a more complete motion 
in the direction of the axis of the limb, by which the danger of push- 



Fig. 235. 




Salter's cradle. (From Fergusson.) 

ing the fragments upon each other is obviated. This is accomplished 
by the rolling of two pulley-wheels upon a horizontal bar. The case 
in which the leg rests may be made of metal or of wood, and the frame 
of iron, for the sake of lightness and strength. 

Dr. Hodgen, of St. Louis, suspends the box over a pulley placed 
transversely, so that by drawing the rope to the right or to the left, 
the box may be turned upon either side. 

Fracture-boxes, employed in the treatment of compound fractures 
of the leg, are, in this country, sometimes filled with bran ; the bran 
being closely packed upon all sides so as to support the limb uniformly 
and gently. This method of treating compound fractures of the leg 
was first suggested by J. Rhea Bar- 
ton, of Philadelphia, 1 and has been fig. 236. 
much used in the Pennsylvania Hos- 
pital ; and latterly it has been in- 
troduced into the Bellevue and New 
York City Hospitals. It possesses 
the advantage of affording a perfect 
protection against flies in the sum- 
mer season, and of absorbing the 
matter as it escapes. 

In Using the " bran-box," the Fracture-box, with movable sides. 

sides are first brought up into posi- 
tion and made fast. A piece of muslin cloth, one yard in length by 




1 Barton, Amer. Journ. of Med. Sci., vol. xvi, p. 31, and vol. xix, p. 515. 



500 



FRACTURES OF THE TIBIA AND FIBULA. 



half a yard in breadth, is then laid upon the box, and into this the 
bran is poured, until it is about one-fourth full. The bran is then 
distributed to as to fit the back of the leg, and the limb is placed in 
position. After which, additional bran is packed on either side of the 
limb, until it is nearly or quite enveloped ; the wounds being first 
covered by pieces of lint smeared with simple cerate. Finally, the 
upper portion of the muslin sack is fastened around the limb just above 
the knee, to prevent the escape of .the bran. 

Whenever any portion of it becomes soiled by blood or pus, it may 
be dipped out with a spoon, and its place supplied with fresh bran. 
The support which it gives to the limb is also uniform without being 
at any time excessive, and Dr. Coates states that the escape of blood 
in rapid haemorrhages has been known to increase the bulk of the bran 
sufficiently to arrest the bleeding by its accumulated pressure. 

In whatever position the leg is placed, and with many of the forms 
of apparatus which we have enumerated, it will be found necessary to 
protect the limb from the weight of the bed- 
clothes by some contrivance similar to that 
figured in the accompanying drawing; or by a 
rack, such as is represented for suspending 
the leg when leather splints or the immovable 
apparatus is employed. 

Malgaigne, who declares that every surgeon 
knows how impossible it is, in an immense 
majority of cases, to overcome the projection 
of the superior fragment when the limb is placed in the extended 
position (over a double-inclined plane), and who affirms that neither 
Pott's position, nor Dupuytren's modification of it, will do much if any 



Fig. 237. 




Wire rack for fracture of leg. 



Fig. 238. 




Malgaigne's apparatus for oblique fractures of the leg. (From Malgaigne.) 



better, nor, indeed, that Laugier's plan of cutting the tendo Achillis 
possesses in this respect any real advantage, concludes at last to resort 
to a new and really ingenious method, the value of which, also, he 
claims to have already fully demonstrated. His apparatus consists 
simply of a steel band of sufficient size to encircle three-fourths of the 
limb, at the two extremities of which are two horizontal mortises 
through which a band is passed, and which may be buckled upon itself 
behind. The centre of the metallic arch, in front, is penetrated with 
a firm metallic screw, terminating in a very sharp point, and which is 
moved by a flat thumb-piece. 



FRACTURES OF THE TIBIA AND FIBULA. 



501 



The limb being laid over a double-inclined plane, and the pads 
being carefully adjusted, as we have already directed when speaking 
of other forms of apparatus, and the limb properly extended, the 
apparatus of Malgaigne is placed over the limb, with the sharp point 
of the screw resting upon the upper fragment, a few lines above the 
point of fracture ; and at the same moment that this point is pressed 
firmly down to the bone, the fragments being held together by an 
assistant, the strap is buckled as tightly as possible under the splint. 
A few turns of the screw will now make its point penetrate more 
deeply into the bone, and insure the most complete apposition of the 
broken extremities. " This is accomplished," says Malgaigne, " with 
very little pain to the patient;" and, as will be seen, the steel arch 
effectually prevents any ligation of the limb. I cannot say that the 
plan receives my unqualified approval; yet I have employed it to 
advantage in some cases of old ununited fractures. 



Fig. 239. 




Malgaignc's apparatus applied. (From Malgaigne.) 

Refracture and Resection of Crooked Legs. — In some cases of extreme 
deformity of the legs consequent upon badly united fractures, resection 
of the bones has been practiced with more or less success. 

The first case of which I have seen any mention made, where the 
bones were actually resected, is reported by Charles Parry, of Indian- 
apolis, Ind. A young man, set. 15, having broken his leg near its 
middle, the fragments united, from some cause, nearly at right angles 
with each other. Some years afterwards, on the 15th day of January, 
1838, Dr. Parry operated, by removing a wedge-shaped portion from 
both the tibia and fibula. The recovery was tedious, but satisfactory. 1 

Mr. Key, of London, made an operation of this kind upon a gentle- 
man who had suffered a fracture of the right tibia from a musket-ball. 
The limb was nearly useless, since he could only bring his toes to the 
ground. Mr. Key operated in October, 1838, and w r hen the report of 
the case was made, live months subsequently, the patient was doing 
well. 2 



1 Parry, Amer. Journ. Med. Sci., Aug. 1839, p. 334. 

2 Kev, Amer. Journ. Med. Sci., Aug. 1839, p. 339; from Guy's Hospital Keports, 
April, 1839. 



502 FRACTUKES OF THE TARSAL BONES. 

In September, 1840, Dr. Mutter, of Philadelphia, made a similar 
operation upon a patient, whose leg was shortened three inches and a 
half, and very much deformed ; by which operation, when the recovery 
was complete, the shortening was considerably reduced. 1 

Cases may occur which will justify a resort to these extreme measures, 
or in which they may be preferred to amputation; but an examination 
of the several examples reported will show that these operations are 
not unattended with danger to the life of the patient; indeed, in this 
respect, amputation has greatly the advantage. If, moreover, the sur- 
geon expects, by this method, to lengthen a limb much, w T here it is 
merely overlapped and shortened, he is, I am certain, destined to dis- 
appointment, at least in all cases where sufficient time has elapsed for 
the bones to have become firmly united. I have myself several times 
refractured a bone ; and I have several times met with cases of old 
fractures newly broken, and I have constantly observed that I could 
never, in the end, make it but very little if any longer than it was 
before the last fracture. The muscles had contracted to that point, 
and their contraction would not be overcome. In the case reported 
by Mutter, he believed that he stretched the muscles two inches. 
With all deference for the skill and honesty of this gentleman, I think 
that he was mistaken. 

If, however, the object of the operation is to straighten the limb, 
then no doubt it may be sometimes accomplished ; and in some degree 
also by the straightening of the limb the shortening may be overcome; 
but, in our opinion, such procedures ought to be reserved for extraor- 
dinary circumstances. 

An instructive case of refracture is reported by Dr. Horner, of 
Philadelphia, in the Medical Examiner. The limb had been broken 
eight weeks, and was quite crooked, but was not very firmly united, 
and Dr. Horner having refractured it, was able at once to restore it 
to a nearly straight line. 2 



CHAPTEE XXXIII. 

FRACTUKES OF THE TARSAL BONES. 

Causes. — The astragalus is generally broken by a fall from a height, 
the patient having struck upon the bottom of the foot. Monahan, in 
an analysis of ten cases, found it had been broken by a fall upon the 
foot nine times, 3 and only once by a crushing accident. 

1 Mutter, Amer. Journ. Med. Sci., April, 1842, p. 359. Three similar cases 
may also be found in the Oct. No. for 1841, and the April No. for 1842 of the same 
journal, in which the operations were made by Portal, of Palermo. Malgaigne 
mentions two other examples. 

2 Horner, New York Journ. Med., May, 1851, p. 432. 

3 Fracture of the astragalus, with analysis of the recorded cases of this injury. 
An inaugural thesis, presented to the faculty of the Buffalo Med. Col , March, 1858, 
by Bernard Monahan, M.D. 



FRACTURES OF THE TARSAL BONES. 503 

The calcaneum is also occasionally broken by violent lateral pres- 
sure, but much more often by a fall upon the foot, or rather upon the 
heel. In some instances both heel-bones have been broken at the same 
moment; but Malgaigne has collected eight cases of fracture of this 
bone by muscular action, as in jumping upon the toes, the posterior 
portion of the bone being thus violently acted upon by the tendo 
Achillis. South, in his Notes to Chelius, has mentioned two other 
cases, one of which was seen by Lawrence, and has been reported in 
the second volume of the Lancet. This person had received the injury 
by jumping off a stage-coach. The fragment was found to be drawn 
upwards slightly, but not so far as to prevent crepitus when the mus- 
cles on the back of the leg were relaxed. The other example mentioned 
by South is a cabinet specimen contained in the museum of St. Bar- 
tholomew's Hospital. The fracture had taken place just below the 
attachment of the tendo Achillis, but the upper fragment w 7 as not dis- 
placed. 1 Mr. Cooper mentions two other cases, both produced by vio- 
lent efforts on the part of the patients to sustain themselves when fall- 
ing. In one of these the fragment was immediately drawn up three 
inches. 2 

The other bones of the tarsus are generally broken by crushing 
accidents, such as the fall of heavy w-eights upon them, by the passage 
of loaded vehicles, etc. 

Pathology. — The astragalus often, indeed generally, escapes without 
injury in those crushing accidents which break many or most of the 
other bones of the foot, and, as we have seen, it is seldom broken 
except when the patient has fallen upon the bottom of his foot; but 
at the same moment, the foot being turned forcibly out or in, a dislo- 
cation of the tibia takes place, and the fibula is broken. In nine of 
the cases collected by Monahan, one or the other of these forms of 
dislocation had occurred, in eight of which the dislocation was com- 
pound. The direction of the fracture is found to vary greatly ; thus, 
it has been found broken in its length antero-posteriorly, in its breadth 
or transversely, and in one instance it has been divided nearly hori- 
zontally, so as to separate the upper face completely from the lower. 
Sometimes it suffers a species of impaction, the fragments being actu- 
ally driven into each other ; at other times, as in one case related 
by Amesbury, the bone may be split without the occurrence of any 
displacement. 

The calcaneum also may be broken in any direction, and it is equally 
with the astragalus liable to impaction, by which its vertical diameter 
is sensibly diminished, while its transverse diameter is increased. If 
the fracture is a consequence of muscular action, the line of fracture is 
always posterior to the astragalus, and in some cases only that portion 
is broken off to which the tendo Achillis has its attachments. It may 
be broken also vertically, directly underneath the astragalus, in which 
case the lateral and interosseous ligaments will prevent anything more 
than a slight displacement of the posterior fragment. When the frac- 

1 South, Notes to Chelius's Surgery, vol, i, p. 639, Amer. ed. 

2 B. Cooper's ed. of Sir Astley, Amer. ed., p. 311. 



504 FRACTURES OF THE TARSAL BONES. 

ture take? place posterior to the lateral ligaments, the detached frag- 
ment is liable to be drawn very far from the body of the bone, even 
to the extent of four or five inches, and possibly farther when the leg 
is extended upon the thigh and the foot flexed upon the leg. Con- 
stance relates a case in which the tuberosity, having been broken off 
by a direct blow, was drawn up five inches. 1 

Fractures of the calcaneum produced by contraction of the sural 
muscles are generally simple, but those which result from a crushing 
of the bone are more often compound. The same remark is applicable 
also to the other bones of the tarsus, the fractures of which, being only 
produced by direct blows, are generally complicated with external 
wounds. 

Symptoms. — All fractures of the bones of the tarsus demand especial 
care in their diagnosis, since only a few of the usual signs of fracture 
are in a majority of the cases presented. The explanation of this fact 
will be found in the number, size, and strength of the bones of the 
tarsus, and in their close and firm union by ligaments, by which they 
give to each other a mutual support, so that the fracture of a single 
bone does not necessarily or usually result in displacement or deform- 
ity, and even crepitus is with difficulty detected ; and when we con- 
sider, moreover, that the fracture is generally produced by great vio- 
lence, directly applied, in consequence of which the foot in most cases 
becomes rapidly and enormously swollen, we shall understand the true 
nature of the difficulties which are usually presented in the way of an 
accurate diagnosis. 

Of ail the usual signs of fracture, crepitus alone is pretty generally 
present, but even this often fails to tell us which bone is broken, and 
still more often does it fail to inform us as to the direction and extent 
of the bony lesions. 

If the whole or a portion of the tuberosity of the calcaneum is sepa- 
rated by the action of the muscles, and the fragment is drawn upwards, 
it may be discovered in its new position, and the heel will be flattened 
or shortened, but no crepitus can be felt unless the fragments are again 
brought in contact. 

Treatment. — Not any of the fractures of the tarsal bones in them- 
selves demand the use of splints, and it is only when complicated with 
a dislocation of the ankle and fracture of the fibula that it is proper 
to employ apparatus of this sort; certainly the exceptions to this rule 
must be very rare; so that our practice in these cases will be confined 
chiefly to the prevention and reduction of inflammation. The limb 
must be placed in the most easy position, and cold water lotions assid- 
uously applied. This will be the sum of the treatment demanded 
during the first few days after the receipt of the injury in probably all 
cases of simple fracture, and in many cases of compound fracture. 

If single bones, or fragments of single bones, are displaced to any 
considerable extent, and there is an external wound communicating 
with the fracture, I have no doubt it would be best in all cases to re- 

1 Constance, Amer. Journ. Med. Sci., vol. v, p. 222, Nov. 1829, from the Midland 
Med. and Surg. Reporter. 



FRACTURES OF THE TARSAL BONES. 505 

move at once by dissection the projecting bone, even although it were 
possible, or perhaps easy, to force it back again to its place, as has been 
done successfully by Ashhurst, of Philadelphia. 1 The same rule I 
would apply to examples of fracture uncomplicated with any external 
wound, if the fragments were very much displaced, and could not by 
the application of moderate force be replaced, since the bone left to 
project would prevent the patient from ever wearing a boot with com- 
fort, and would entail as much weakness upon the limb as would be 
likely to follow from its complete separation. But such cases as I 
have last supposed are exceedingly rare ; indeed, I have never met 
with a simple fracture of a tarsal bone accompanied with displacement. 

Norris has, however, reported a case of fracture of the astragalus 
accompanied with displacement of about one-half of the bone, but 
without any lesion of the soft parts. This was in the person of a man 
set. 30, who was admitted into the Pennsylvania Hospital on the 26th 
of Sept. 1831. "An hour previous to admission, Avhile descending a 
ladder, he slipped and fell in such a manner as to throw the entire 
weight of his body upon the outer part of his left foot. Upon exami- 
nation, the foot was found to be turned inwards and nearly immovable. 
A slight depression existed immediately below the lower end of the 
tibia, and there was a considerable hard and rounded projection on the 
outer part of the foot, a little below and in front of the extremity of 
the fibula. The skin covering this projection was reddened, but not 
excoriated. There was no fracture of either bones of the leg." 

These appearances led Drs. Norris and Barton, under whose care 
the patient was placed, to regard the accident as a simple luxation of 
the astragalus forwards and outwards ; and a short time after admission 
efforts were made to reduce it. " This was done, after relaxing in as 
great a degree as possible the muscles of the leg, by fixing the knee, 
and having assistants to keep up extension, by seizing the heel and 
front part of the foot; at the same time the bone being pushed inwards 
and toward the joint by the surgeon. These eiforts were continued 
for a considerable time, but had no effect in changing the position of 
the bone. 

" Six hours afterwards Drs. Huston and Harris saw the patient in 
consultation, when efforts were again made at reduction, which not 
proving more effectual than in the first trial, the excision of the bone 
was determined on. 

" The patient being properly placed, an incision was made through 
the integuments, parallel with the course of the tendons, commencing 
a short distance above the projection on the foot, and extending down 
far enough to expose fairly the astragalus and its torn ligaments. The 
bone was then seized with forceps, and easily removed after the division 
of a few ligamentous fibres that continued to connect it to the adjoin- 
ing parts. 

" Very little hemorrhage occurred, two small vessels only requiring 
the ligature. 

1 Ashhurst, Amer. Journ. Mod. Sci., April, 1862. 
33 



50() FEACTUKES OF THE TARSAL BONES. 

"After removal it was discovered that about one-half of the surface 
which plays in the lower end of the tibia had been fractured, and re- 
mained firmly attached to the extremity of that bone, and as it was 
judged that the efforts to remove this would be likely to produce more 
injury to the joint than would arise from allowing it to remain, no 
attempt was made to extract it. 

" The joint being carefully sponged out, the sides of the incision 
were brought accurately together by means of sutures and adhesive 
straps, after which simple dressings and a roller were applied, and the 
foot, restored to its natural situation, placed in a fracture-box." 

Subsequently that portion of the astragalus which was permitted to 
remain, having become carious and loosened, was removed also. 

The case continued to do badly ; all the bones of the tarsus, and 
even the lower ends of the tibia and fibula, becoming eventually cari- 
ous ; and on the 27th of March, 1853, more than a year and a half 
after the receipt of the injury, the leg was amputated ; but no healthy 
action ensued, and the patient soon died. 1 

The result of this case can scarcely be regarded as having settled any- 
thing in reference to the value of the procedure which I have recom- 
mended. For reasons which seemed satisfactory to the surgeons who 
made the operation, only one-half of the broken bone was removed ; 
whether the result would have been different if the whole had been at 
once taken away, we cannot now determine. I have related it, how- 
ever, as the only example of a simple fracture with displacement which 
I have been able to find upon record ; and in this case, several sur- 
geons of merited distinction concurred in the opinion that the protrud- 
ing fragment ought to be removed. 

A fracture of the posterior portion of the calcaneum, especially when 
it has been produced by muscular action, constitutes an exception to 
fractures of the tarsal bones generally, and demands usually that appa- 
ratus of some kind should be employed in its treatment. 

In order to replace the posterior fragment when displaced, or to main- 
tain it in apposition until a bony union is accomplished, it will be neces- 
sary to shorten the gastrocnemii by flexing the leg upon the thigh and 
extending the foot upon the leg. But to retain the limb in this position 
it will be expedient always to employ apparatus. A very simple con- 
trivance, however, will generally answer all the indications. A band- 
age, padded strap, or a stuffed collar may be fastened about the thigh 
just above the knee, and made fast to the heel of a slipper by a tape 
(Fig. 240). The apparatus is the same which has been recommended 
for a rupture of the tendo Achillis. 

In addition to this, the limb ought to be covered from the foot up- 
wards as far as the knee with a snug roller, underneath which, on each 
side of and above the detached fragment, ought to be placed suitable 
compresses, the object of the roller being to diminish muscular con- 
traction, and the compresses being intended to retain the detached 
piece in contact with the main body of the bone. Some surgeons have 

1 Norris, Amer. Journ. Med. Sci., vol. xx, p. 379. 



FRACTURES OF THE METATARSAL BONES, 



507 



not found it necessary to flex the leg upon the thigh ; but they have 
contented themselves with extending the foot upon the leg, and con- 
fining it in this position by a splint 
of wood or gutta-percha laid along fig. 240. 

the front of the leg, ankle, and foot. 
In still other cases, the fragment has 
shown so little disposition to become 
displaced as to render no precautions 
of any kind necessary, except to im- 
pose upon the patient complete quiet, 
with the limb resting upon its outside 
and flexed, as in Pott's fracture of the 
fibula. 

As soon as the inflammation has 
sufficiently subsided, passive motion 
must be given to the ankle, in order 
to prevent, as far as possible, the 
anchylosis which is an almost con- 
stant result of these accidents. In- 
deed, the patient is fortunate who re- 
covers a tolerable use of his foot after 
the lapse of many months; nor can 
he be assured that the inflammation 
will leave these bones and their dense 
fibrous envelopes for a long period, 
and that it^may not result in caries of 
more or less of the tarsal bones, de- 
manding finally amputation of the 
whole foot. 

We have not intended to speak in 
this place of those severer accidents, 

accompanied with comminution and extensive laceration, which forbid 
the hope of saving the foot, and for which immediate amputation is the 
only proper resource, but which constitute, in fact, the great majority of 
all the fractures of the tarsal bones. 




Apparatus for fracture of the tuberosity of the 
calcaneum. 



CHAPTEE XXXIV. 



FRACTURES OF THE METATARSAL BONES. 



These bones can scarcely be broken except by direct blows, and the 
great majority of their fractures are the results of severe crushing acci- 
dents, such as render amputation sooner or later necessary. Of those 
which do not demand amputation, by far the largest proportion are 



508 FRACTURES OF THE METATARSAL BONES. 

compound fractures ; of which class the following example will serve 
as an illustration : 

A man in the employ of one of the railroads which connect with 
this city was run over by a loaded car on the 14th of June, 1856, 
crushing his right arm so as to render its immediate amputation neces- 
sary. I found also a compound comminuted fracture of the fourth 
metatarsal bone of the right foot. Considerable haemorrhage occurred 
from the wound, but this ceased spontaneously. Cool water dressings 
were diligently applied, without splints or bandages, and although 
some inflammation and suppuration ensued, the parts finally healed 
over and the fragments united, w T ith only a slight backward displace- 
ment at the seat of fracture. 

When only one bone is broken, the displacement is usually very 
trivial ; but when several are broken, it may be considerable. Mal- 
gaigne relates an example of this latter accident in which, the three 
middle bones being broken by the wheel of a carriage, and the integu- 
ments being badly torn and bruised, it was found impossible to retain 
the fragments in place. The patient recovered, and was able to place 
the foot well to the ground, but the proximal fragments continued to 
project upwards upon the top of the foot to such a degree as to require 
a special shoe. 

In a majority of cases the direction of the displacement is backwards 
(upwards), especially when the middle metatarsal bones are the sub- 
jects of the fracture. 

I have in my cabinet a second metatarsal bone broken obliquely 
near its middle, with only a very slight displacement of the lower frag- 
ment backwards ; and also the cast of a bone which has united with an 
enormous backward projection. 

In one instance I have seen the metatarsal bone of the little toe cut 
in two with an axe, and the fragments united in about thirty days, but 
with the lower fragments slightly displaced outwards. 

Delamotte relates a case also in which the first four metatarsal bones 
were cut off, and complete union was accomplished on the fortieth day ; 
at the end of two months the patient walked without lameness. 

Treatment. — If the fragments are not displaced, nothing is required 
except that the foot shall be kept at rest, and the inflammation con- 
trolled by suitable means. 

In case, however, a displacement exists, it ought to be remedied, if 
possible, since, if only very slight, it may become the source of a serious 
annoyance. If the fragments project upwards, they interfere with the 
wearing of a boot, and if they sink toward the sole, the skin beneath is 
liable to remain constantly tender, and the patient may thus be seri- 
ously maimed for life. 

In case the displacement is not due to the action of the muscles, but 
only to the nature and direction of the force producing the fracture, or 
to entanglement of the broken ends, and it is likely to cause any of the 
inconveniences which I have mentioned if permitted to remain, it will 
be advisable at once to employ considerable force in the way of pres- 
sure, or to elevate the fragments through an opening previously made 



FRACTURES OF THE PHALANGES OF THE TOES. 509 

upon the dorsum of the foot, calling to our aid even the saw or the 
bone-cutters, if necessary. After which the fragments may be retained 
in place by carefully applied pasteboard splints and compresses. 



CHAPTER XXXV. 

FRACTUEES OF THE PHALANGES OF THE TOES. 

If fractures of the other bones of the foot are generally of such a 
character as to require immediate amputation, these fractures demand 
this extreme resort still more often. Our experience, therefore, in the 
treatment of fractures of the phalanges of the toes is extremely limited. 

Lonsdale observes that it is not uncommon to find great irritation 
arise after fracture of the great toe ; an inflammation extending along 
the absorbents on the inside of the leg to the groin, causing abscesses 
to form in different parts of the limb, and producing sometimes great 
constitutional disturbance. An illustrative case has come under my 
own observation at the Buffalo Hospital of the Sisters of Charity. The 
patient, Morgan McMann, set. 18, was admitted Dec. 23, 1853, having 
several days before received an injury upon the great toe which con- 
tused the flesh severely and broke the first phalanx. He was then 
suffering from severe pain in the foot and leg, and the absorbents were 
inflamed quite to the groin. Poultices being applied to the foot and 
cool lotions to the limb, the inflammation soon subsided, but not until 
a portion of the toe had sloughed away. Eventually also it became 
necessary to remove some portion of the phalanx, which had died ; 
after which the wounds healed kindly. 

When any of the smaller toes are broken, it will be found easier to 
support the fragments by a broad and long splint which shall cover 
the whole sole of the foot and all the toes at the same time, than to 
attempt to apply a splint to the broken toe alone. If, however, we 
prefer this latter mode, a thin piece of gutta perch a will be found alto- 
gether the most convenient material for the purpose. 

If the great toe is broken, its great breadth may prevent any dis- 
placement, and a well-moulded gutta-percha splint will generally 
secure a perfect and rapid union. 



510 GUNSHOT FRACTURES. 






CHAPTER XXXVI. 

GUNSHOT FRACTURES. 

Gunshot fractures have already been considered, more or less in 
detail, in the several portions of this work, wherever it seemed to be 
necessary to call especial attention to them. This chapter will be de- 
voted, therefore, to a brief resume of my own observations and con- 
clusions in this department; to which will be added a few general 
statistical statements, drawn chiefly from the published records of the 
late war. 

Causes. — Gunshot fractures are caused by a great variety of missiles, 
such as musket and rifle balls, solid shot and shell, grape, canister, 
shrapnel, chain and bar shot, fragments of iron, stone, splinters of 
wood, etc., etc. The only qualities which these missiles possess in 
common is, that they are all projected by the elastic power of gun- 
powder, and generally strike the body with great force ; and that they 
cause fractures by direct violence — seldom if ever by counter-stroke. 

Round, smooth balls frequently impinge upon bones without caus- 
ing a fracture, for the reason that they are easily deflected ; and this 
happens especially when they are not moving with great velocity. 

Conical rifle-balls seldom fail to fracture the bones which lie in their 
direct course ; never, perhaps, when, at the moment of contact, the ball 
is moving with its average velocity. The peculiar destructiveness of 
this missile is due to its weight, momentum, and form. 

Canister, grape, shrapnel, solid shot, shells, chain and bar shot, are 
still more destructive; generally tearing the limbs from the body in 
such a manner as to render readjustmeut and restoration impossible. 

Pathology. — These fractures may be simple, compound, comminuted, 
or complicated ; and in addition to these common varieties of fractures 
there is occasionally presented an example of simple " perforation," or 
mere penetration of the bone without fissure or other fracture ; and 
still more frequently are seen examples of perforation with fissures. 

Probably ninety-nine per cent, of all gunshot fractures are both 
compound and comminuted ; the comminution being, in general, ex- 
cessive. 

As in gunshot wounds of the soft parts it has been generally ob- 
served that the point of entrance is more round, more smooth, and 
somewhat smaller than the point of exit, and that the tissues are a 
little depressed at the entrance, while they are slightly protruded at 
the exit, so also in gunshot fractures it will often be found that the 
side of the bone on which the ball has entered, or upon which it first 
impinged, is less comminuted than the opposite side ; and, if it is a 
" perforation," that the opening is smaller upon the one side than upon 
the other; that the edges are slightly depressed upon the one side, and 



GUNSHOT PEACTUKES. 511 

elevated or protruded upon the other; and, finally, that numerous 
small, as well as some large, fragments of bone have been carried into 
that portion of the track of the wound which lies between the bone 
and the point of exit of the missile. 

When a ball fractures the shaft of a long bone, although the blow 
may have been received three, four, or even six inches from an articu- 
lation, the comminution or a single longitudinal fissure may sometimes 
be found extending into the joint. These fissures or splittings of the 
shaft often extend also a long distance up or down, without termina- 
ting in the joint. 

Perforations without fissure occur most often in the broad bones of 
the pelvis, in the scapula, or in the spongy extremities of the long 
bones. In the latter, however, it is exceedingly rare to find perfora- 
tion without fissure. 

Perforations with fissure are pretty common in the head of the hu- 
merus and in the head of the tibia ; they occur also, but less often, in 
the lower ends of the femur and tibia, in the trochanteric portion of 
the femur, and in the head of the femur. We wish to be understood 
to say that fissures occur less often at the points last mentioned, simply 
because perforations are there less common. It must be known that if 
perforations do occur at these points, a splitting or fissure communi- 
cating with the joints is almost inevitable. A misunderstanding here 
would lead to a very fatal error in many cases. 

Prognosis. — In general it may be stated that gunshot fractures of 
the upper extremities do not demand amputation, and that similar in- 
juries in the lower extremities do demand amputation. 

This statement is very broad, and cannot be understood except by a 
consideration of these accidents somewhat in detail. Thus: 

Gunshot fractures of the clavicle, scapula, of the shaft of the hu- 
merus, of the shafts of the radius and ulna, and of the carpal, meta- 
carpal, and phalangeal bones, notwithstanding these bones have suffered 
extensive comminution, do not usually demand amputation ; they will 
in most cases eventually unite, and give to the patients tolerably useful 
limbs. If, however, at the same time that the shaft of the humerus, 
or of the radius and ulna, is thus broken, the large nervous trunks are 
torn asunder, so that the extremity is cold and insensible, the limb 
cannot probably be saved, nor, if it could be, would it be of any value. 
Destruction of the main artery supplying the limb diminishes the 
chance of its being saved, but does not, in the case of the upper ex- 
tremities, necessarily demand amputation. 

Penetration of the shoulder-joint by a musket or rifle ball, producing 
a fracture of the head of the humerus or of the glenoid cavity of the 
scapula, demands amputation when either the axillary artery or axil- 
lary nerves are injured ; but resection can generally be practiced with 
a reasonable chance of success when the arteries and nerves are un- 
touched. Resection is also made successfully at the shoulder-joint in 
some cases where larger missiles have traversed the joint, such as can- 
ister, fragments of shell, etc. 

Penetration of the elbow-joint by a large shot, or by a Minie rifle- 



512 GUNSHOT FRACTURES. 

ball, the missile fairly entering or traversing the joint, demands ampu- 
tation when the main arterial and nervous supplies are cut off', and 
resection, generally, when both remain uninjured. Resection may be 
attempted at the elbow-joint, also, in some cases where, the nervous 
supply remaining good, only one of the principal arterial trunks is 
cut off. 

Frequently a ball strikes the outer or inner condyle of the humerus, 
making but a small opening into the joint, and producing only slight 
comminution, and in such cases we often save the limb with more or 
less anchylosis, and without resection. 

The remarks which we have made in reference to gunshot fractures 
of the elbow-joint apply, almost without qualification, to the same 
accidents at the wrist-joint. 

For gunshot wounds with fracture of the carpal, metacarpal, and 
phalangeal bones we seldom practice either resection or amputation, 
unless the soft parts are almost completely torn away. 

The prognosis which, as we have now seen, is so favorable in the 
upper extremities, will be found very different in the lower extremi- 
ties; indeed, it is almost reversed. Thus: 

Gunshot fractures of the shaft of the thigh, of the shafts of the tibia 
and fibula, and of the tarsal bones, generally demand amputation ; or, 
to be more precise, gunshot fractures of the head and neck of the femur 
almost always terminate fatally under amputation or excision, and 
equally under treatment as fractures, that is, where an attempt is made 
to save the limb without interference with the knife. The same acci- 
dents in the upper third of the shaft of the femur are generally fatal ; 
but if the main artery and the principal nerves are uninjured, the life 
is, in general, less hazarded by an attempt to save the limb than by 
amputation. In the middle third, under the same circumstances, the 
chances may be considered equal, as between amputation and the 
attempt to save the limb by apparatus ; in the lower third the chances 
are in favor of amputation. 

The above statements in relation to fractures of the femur are based 
mainly upon my own experience, and have been carefully considered. 

I have seen no resections of the knee-joint, and but few of the shaft 
of the femur, after gunshot fractures, which have not terminated fatally ; 
and I am convinced that they should never be attempted in fractures 
of the thigh, unless it be that case which presents so little hope in any 
direction, viz., gunshot fracture of the head or neck of the femur. 

Gunshot fractures of the shafts of both tibia and fibula demand 
amputation where the comminution is extensive, or the pulsation of 
the posterior tibial artery is lost, or the foot is cold and insensible. 
We do not mean to say that some limbs thus situated have not been 
saved, but only that the attempt to save such limbs greatly endangers 
the life of the patient, while amputation at or below the knee is rela- 
tively safe. 

Amputation is the only safe expedient in deep penetrating wounds 
of the tarsal bones produced by missiles of the size of musket-balls or 
larger. The only exceptions, which can safely be made, are in cases 
where balls have opened partially and superficially these articulations. 



GUNSHOT FRACTURES. 513 

Resections at the ankle-joint are much more hazardous than ampu- 
tations, and scarcely to be preferred, in army practice, to attemjjts to 
save the foot without surgical interference. 

Treatment. — While considering the prognosis in these accidents, I 
have necessarily spoken of the treatment in certain cases; especially 
with a view to the propriety of amputation or resection. It remains 
only to speak briefly of the treatment of those cases in which we may 
attempt to save the limb without resection, properly so called ; for we 
must not forget that pretty often we find it necessary to remove small, 
loose fragments of bone by the finger, or by the aid of the knife, or to 
resect sharp points with the saw or the bone-cutters, when we do not 
practice " resection," in the sense in which this term is usually em- 
ployed by surgical writers. 

I shall take the liberty, in this connection, of reproducing what I 
have written elsewhere in relation to gunshot fractures, since it com- 
prises nearly all that seems necessary to be added upon this subject. 1 

" If an attempt is made to save a limb badly lacerated and broken, 
certain conditions in the treatment are necessary to success. 

"All projecting pieces of bone which cannot be easily replaced and 
are not firmly attached to the soft parts, must be at once cut or sawn 
away. 

"All foreign substances, such as fragments of balls or other missiles, 
pieces of cloth, wadding, dirt, etc., must be removed. 

"Any portions of integument, fascia, or muscles, which are entangled 
in the wound, and prevent a thorough exploration, or may obstruct 
the free escape of blood or of matter, must be freely divided. 

"Counter-openings must be made at once, or at an early period after 
the formation of matter, to insure its easy escape. 

" The limb must be pla?ed in an easy position, and not confined by 
tight bandages or forcibly extended by apparatus. 

" The inflammation must be controlled by constitutional and local 
means, and especially by the use of water lotions whenever their em- 
ployment is practicable." 

If joints are implicated seriously, and an attempt is still made to 
save the limb, the joint surfaces must be laid freely open, so as to pre- 
vent all possibility of the confinement of blood, serum, or pus; and the 
joint must be placed perfectly at rest, without adhesive strips, bandages, 
or any apparatus which shall compress the limb or embarrass its circu- 
lation. 

I do not know that it is necessary to speak more particularly of the 
treatment of gunshot fractures, unless it be to say that I still give the 
preference, in fractures of the femur, to the straight position. In most 
cases I have preferred my own apparatus, already described when 
speaking of fractures of the thigh in general, with moderate extension; 
and by moderate extension is to be understood such as may be effected 
with from five to ten pounds. 

1 Treatise on Military Surgery, by Frank Hastings Hamilton. lvol.,8vo. Pub- 
lished bv Bailliere Brothers. New York, 1861 ; also enlarged ed. of same work in 
1865. 



514 



GUNSHOT FRACTURES. 



A movable canvas, such as is shown in the accompanying woodcut, 
with a hole in the centre, and reinforced by an additional piece of 
canvas where the weight of the hips rests, will enable the surgeon to 



Fig. 241. 




Author's movable canvas. 



move his patient and clean the bed when necessary. The standard 
which supports the pulley can be received in a slot in the frame. 

An apparatus similar to this was used, during our late war, in the 
Lincoln General Hospital at Washington. 



Fig. 242. 




Movable canvas, with extension, on "horses." 



I have also used, with the movable canvas, and upon an ordinary 
bed, Hodgen's apparatus, or " cradle," as he terms it, and have found 
it exceedingly useful, and much preferable to any form of double-in- 
clined plane, whether suspended or not. The cradle is simply a skele- 
ton-box, of the length of the thigh and leg, made of light strips of wood. 



GUNSHOT FRACTURES. 



515 



Across the two upper bars are laid, transversely, cloth bands, upon 
which the limb is laid at full length. 1 



Fig. 243. 




Fig. 244. 




Hodgen's apparatus for gunshot fractures of the thigh. 

Of gunshot fractures of the femur many hundreds, probably many 
thousands, during and since the close of our civil war, have come under 
my observation ; but of these, only 92 have been made the subject of 
especial record. Of this number, 75 were fractures of the shaft of the 
femur ; 9 being fractures of the upper third ; 36 of the middle third ; 
and 30 of the lower third. Nearly all of these fractures were caused 
by the conical rifle-ball. They were treated in various Federal and 
Confederate hospitals by a great variety of methods, and under a variety 
of circumstances, which latter were sometimes favorable and sometimes 
unfavorable. The results may, therefore, be regarded as furnishing a 
fair basis for conclusions as to what may reasonably be expected in army 
surgery, or during the progress of a great war. I have a strong con- 
viction, however, that if in an equal number of cases the straight po- 
sition, with moderate extension, were to be employed, and the circum- 
stances were as favorable as are usually found in civil hospitals, the 
results would be considerably better than are here shown. Indeed, my 
own recorded cases show, in a marked degree, the advantages of the 
straight position, with slight extension, over the double-inclined planes. 
In a number of these cases, while the limb was flexed, the shortening 
and bending were excessive, and the substitution of Buck's apparatus, 
Hodgen's, or my own, has made at once a great improvement in both 
regards, besides contributing manifestly to the comfort of the patients. 

The average shortening in those fractures of the shaft of the femur, 



1 Hodgen, Treatise on Military Surg., by the author, p. 408. 



516 GUNSHOT FRACTURES. 

which were measured by myself, was, in the upper third, two inches 
and one-eighth ; in the middle third, two inches and one-quarter; and 
in the lower third, a little more than one inch and a half. In the 
upper third three were shortened two inches or more; the greatest 
shortening being three inches and one-quarter. In the middle third, 
twenty w r ere shortened two inches or more, six three inches or more, 
two four and a half, and one five inches. In the lower third, two were 
shortened two inches or more; the greatest shortening being two inches 
and three-quarters. 

In a large proportion of the cases the thigh was bent at the point of 
fracture, the' bend being in most cases outwards, or to the fibular side 
of the limb. Where N. R. Smith's suspension apparatus was used, the 
bend was usually backwards, while in most of the cases treated in the 
straight position, with moderate extension, the limb was nearly or quite 
straight. 

It is somewhat remarkable that in this table of ninety-two cases 
there are only three examples of union delayed beyond four months, 
and one of these patients was evidently about to die. In a pretty large 
proportion of cases the union was not delayed much beyond the usual 
period of union for a simple fracture, although the limb might be 
much shortened and crooked, and still discharging pus, with frag- 
ments of bone occasionally. 

Among the cases which have come under my especial notice are a 
few of peculiar interest, and which deserve to be particularly mentioned. 

Limb Lengthened. — Melchior Brietel, private 12th N. Y. Volunteers, 
was wounded in June, 1862, at the battle of White Oak Swamp, Va., 
by the fragment of a shell, which struck the left leg three inches above 
the condyles. He was taken to Richmond as a prisoner, and about a 
month later he was exchanged and sent within our lines. January 1, 
1864, I found him in the United States General Hospital at Newark, 
under the charge of Surgeon Taylor. The wound was still discharg- 
ing matter occasionally, and several fragments of bone had been re- 
moved. Splints were not applied until after his exchange. No exten- 
sion was ever employed. At the end of four months he began to walk 
about with crutches. 

On measuring I found this limb lengthened half an inch, and this 
measurement was confirmed by Surgeon Taylor and others. There was 
no anchylosis at the knee-joint. 

It is doubtful whether, in this case, the shaft was broken across en- 
tirely ; if it was, probably no displacement ever occurred. The most 
reasonable supposition is that the fragment of shell entered the bone, 
and that it was in the bone at the time of my last examination, and 
that, in consequence of its presence, the bony structure had become 
hyperaemic, and had undergone hypertrophy in the direction of the axis 
of the limb. 

Perforating and Penetrating Wounds of the Femur. — James S. Mus- 
sey, of 16th N. Y. Volunteers, was wounded at Gaines's Mill, June 27th, 
1862, probably by a round ball. The ball entered the right nates from 
behind, passing entirely through the right trochanter; a finger could 
be thrust through the round, smooth hole in the bone. When I saw 



GUNSHOT FRACTURES. 517 

him, three months after the accident, at Baltimore, under the care of 
Surgeon Hasson, the wound was still discharging pus, but in no other 
way was the injury causing either local or general disturbance. 

At the same time, also, my attention was called to the case of Henry 
Voger, 20th Mass. Volunteers, who was wounded June 30th, 1862, at 
the battle of White Oak Swamp, Va. A ball had entered the lower 
end of the femur, near the joint, in front, but did not pass through, 
and had not, up to this time, been found. Three months had passed 
since the injury was received, and the wound was now entirely closed, 
the knee-joint being anchylosecl; but in other respects the condition of 
the limb was almost normal. At no time was there much inflamma- 
tion of the soft parts in the neighborhood of the injured structures. 

Sergeant Lewis Monell, of the 119th N. Y. Volunteers, Avas wounded 
July 1st, 1863, by a ball, which entered on the outside of the left thigh, 
within one inch of the lower end of the femur, passing forwards, and 
emerging in front above the patella. Four months after the accident 
I found him at the Fifty-first Street United States General Hospital, 
New York City. Several fragments of bone had escaped; the limb 
was bent to an acute angle, and pus was still discharging from the 
wound. There was no effusion into the joint, and his ultimate recov- 
ery seemed to be assured. 

H. O. C. was a private in the French army in the Crimea, when he 
was wounded in his left leg by a ball which passed through the bone 
from before backwards just above the patella. Synovia with pus dis- 
charged for several months, and three small fragments of bone escaped. 
In seven months the wound became permanently closed. When I ex- 
amined the limb in 1864 the joint was a little deformed, and slightly 
anchylosed, but in other respects sound. 

These examples of recovery after gunshot injuries of the femur in 
the vicinity of the knee-joint, must be understood to constitute rare ex- 
ceptions to the rule. In most cases such perforations have been accom- 
panied with longitudinal fissures involving the joint, as is illustrated in 
Fig. 1 of this volume; and attempts to save the limbs have resulted 
in the loss of the lives of the sufferers. 

Fracture from Duelling Pistol — Recovery ivithout .Lameness. — In 
the somewhat famous duel fought between J. C. Breckenridge and 
Frank Leavenworth, on Navy Island, June 7th, 1855, with duelling 
pistols, at ten paces, Breckenbridge was shot in the calf of the leg, and 
Leavenworth through both thighs. After Leavenworth fell he was 
carried in a small boat to a point known as Fort Schlosser on the 
American side of the Niagara River, and placed in a wooden cabin, the 
only tenement in the place. I was at once summoned, but did not 
reach there until the following day. Drs. Grimes, Church, and Ware 
were already present. We found that the bullet had entered his right 
thigh about eight inches above the knee, and passed through the limb 
in front of the bone. The ball then entered the left thigh a little 
further back and a little lower down, striking the femur and breaking 
it about five or six inches above its lower end. Here the ball was ar- 
rested, probably being deflected and becoming lodged in the flesh, and 
it was never found; nor did it ever afterwards cause any trouble. 



518 GUNSHOT FRACTURES. 

I visited Leavenworth, in consultation with Drs. Ware and Church, 
once or twice each week until his recovery was complete. During the 
first few days no apparatus was applied, but the broken limb was sup- 
ported by junks, and both limbs were kept cool and moist with evapo- 
rating lotions. On the eighth day a long side-splint was applied 
(Boyer's), with a perineal band for counter-extension, and a screw for 
extension. The amount of extension was varied from day to day, but 
it was never more than could be comfortably borne. Still later short 
side or coaptation splints were applied. At the end of eight weeks the 
long splint or extending apparatus was removed, and a few days after 
the coaptation splints. Eleven weeks after the accident he was on 
crutches. The femur was then found shortened half an inch, and per- 
fectly straight. 

Mr. Leavenworth survived this injury many years, and although he 
led a very active life, he never suffered any inconvenience from the 
wounds in either limb, and his gait was perfect. 

It is probable that in this case there was no comminution of the bone; 
and I think the same thing has happened under my observation several 
times, where the femur has been broken by a round ball, or by a coni- 
cal ball whose force was nearly expended. A conical ball at short 
range, when it strikes the shaft of the femur fairly, can never fail to 
cause extensive comminution. 

Missiles remaining in the Bone. — Lieutenant Champlain (subsequently 
Commodore) was wounded by a bullet, in 1813, during a sortie from 
Fort Erie, on the Niagara frontier. The ball entered about the middle 
of his thigh and buried itself in the bone. Subsequently Dr. William 
Gibson, of Philadelphia, and still later, Dr. Nathan Smith, of New 
Haven, attempted the removal of the ball, but without success. 

During all of his long and active life his limb continued to give him 
serious trouble at intervals, and I was several times called to open ab- 
scesses which had suddenly formed, but I was never able to find the 
ball. The limb was firm, somewhat shortened, and strongly rotated 
outwards at the point of fracture. 

Lieutenant Charles Payson, aid-de-camp to General Devins, was 
wounded by the fragment of a shell while leading a charge upon a 
portion of the enemies lines at the battle of Cold Harbor, Va., June 
1st, 1864. 

The missile entered about the middle of the left thigh, breaking and 
comminuting the bone. Surgeon Rice, of the 25th Mass. Volunteers, 
removed on the same day one fragment of bone about two inches in 
length by half an inch in breadth, but the piece of shell could not be 
found. On the third day he was taken to Chesapeake Hospital, near 
Fortress Monroe. Subsequently the surgeon in charge removed with 
a saw portions of both fragments. 

October 24th, nearly five months after the receipt of the injury, I 
was summoned to the hospital to see Lieutenant Payson in consulta- 
tion. I found the limb suspended in Smith's anterior splint, the two 
separated ends of the broken femur pointing backwards at an angle of 
45°, and nearly projecting from the wound. This is the position which 



GUNSHOT FRACTURES. 519 

I have seen the fragments take in very many, probably in a majority, 
of the gunshot fractures of the shaft of the femur treated by this ap- 
paratus ; and which vicious position the surgeon had in vain sought to 
prevent in the case of Lieutenant Pay son. 

Having removed three or four detached fragments of dead bone, we 
laid the limb in a straight position upon a Hodgen's splint or cradle, 
while permanent extension was made with a weight and pulley secured 
to the leg by adhesive strips. The amount of extension employed was 
eight pounds. The fragments were now in line, and the patient de- 
clared that he was much more comfortable. 

March 31st, 1865, five months after this change in the mode of 
dressing had been adopted he was brought to New York greatly im- 
proved in health, the bone firmly united, with a slight outward bend 
at the seat of fracture, and shortened six and a half inches, and with 
almost complete anchylosis of the knee-joint. 

From this time Lieutenant Payson remained constantly under my 
charge for two or three years, when at length the wound became per- 
manently closed, and his health was completely re-established. In the 
meanwhile, however, after his return to New York, the original wound 
discharged more or less constantly, and occasionally abscesses of con- 
siderable size were formed which had to be opened. On the 8th of 
November, 1865, seventeen months after the wound was received, it- 
was my good fortune to detect the position of the fragment of shell 
which had caused all this trouble. I had searched for it many times 
before, but on this occasion a Nekton's probe disclosed an iron-rust 
mark by which I was guided to its bed in the centre of the bone, and 
from which it was at once removed. 

As supplementary to this chapter, it seems proper to add a brief 
resume of the statistics of the late civil war, drawn from the reports 
of the Surgeon-General, made in 1865 and in 1867. 1 

Of 4167 gunshot wounds of the face, 1579 were accompanied with 
fractures of the facial bones. Of these latter, 107 died, and 891 re- 
covered. The remainder are undetermined. Secondary haemorrhage 
is said to have been the most frequent cause of death. 

Of 187 examples of gunshot injuries of the spine (not including 
those in which the chest or abdomen was penetrated), 180 died. Six 
of those reported as having recovered were examples of fracture of the 
transverse or spinous processes. The seventh is that of a soldier 
wounded at Chickamauga, September 20th, 1863, by a musket-ball, 
which fractured the spinous process of the fourth lumbar vertebra, and 
penetrated the vertebral canal. The ball and fragments of bone were 
extracted, and one year after he was reported as " likely to recover." 

Of 359 gunshot wounds of the pelvis (not including those in which 
the abdominal cavity was penetrated), 77 died, and 97 recovered. In 
the remainder the result is not ascertained. In 256 cases the ilium 
alone was injured; in 19, the ischium alone; in 12, the pubes ; in 32, 
the sacrum ; and in 40 cases the lesions extended to two or more por- 
tions of the innominata. Pyaemia was a frequent cause of death. 

1 Circular No. 6, Surgeon-General's Office; also Circular No. 7. 



520 GUNSHOT FRACTURES. 

Of 1689 gunshot fractures of the humerus, 436 died, and 1253 re- 
covered. Nine hundred and ninety-six of these 1689 cases were treated 
by amputation or resection, with a mortality of 21 per cent. In 693 
cases the conservative treatment was adopted, with a mortality of 30 
per cent. 

Of 68 cases in which attempts were made to save the limb after gun- 
shot injury of the hip-joint, without resection, all died. (I have seen 
two cases of successful treatment of these accidents by the conservative 
plan, and others have been reported.) 

Fifty-three amputations at the hip-joint, made by surgeons in the 
Federal and Confederate armies, including also reamputations, gave 
seven successful results. The fate of two is uncertain. 

Sixty-three excisions at the same joint, made by Federal and Confed- 
erate surgeons, furnished five successful cases. 

Three hundred and thirty cases of gunshot fracture of the upper 
third of the shaft of the femur, in which neither amputation nor resec- 
tion was practiced, gave a mortality of 71.81. Thirty-two cases in 
which amputation was made gave a mortality of 75 per cent. Twenty- 
two in which resection was made, gave a mortality of 81.18. (We have 
rejected three cases given in the report as cured. Two of these were 
resections of the head, and one was merely a " rounding off of sharp 
edges. ") 

Two hundred and thirty-two cases of gunshot fractures of the mid- 
dle third, treated without amputation or resection, gave a mortality of 
55.46. Ninety-three treated by amputation gave a mortality of 54.83. 
Fifteen treated by resection gave a mortality of 86.66. 

One hundred and seventy-three gunshot fractures of the lower third, 
treated without amputation or resection, gave a mortality of 57.79. 
Two hundred and forty-three amputated — mortality 46.09. Two re- 
sected — both died. 

Of 308 gunshot wounds of the knee-joint, with or without fracture, 
treated without amputation or resection, 258 died — mortality 83.76. 
Of the 50 which recovered there were, however, only six or eight in 
which the testimony is unequivocal that the joint was opened. Of 452 
amputated, 331 died — mortality 73.23. Of 10 resected, 9 died — mor- 
tality 90 per cent. 

Of 696 gunshot fractures of the leg, 169, or 24 per cent., were fatal. 

No analyses have been made of fractures of the smaller bones. 

It is much to be regretted that in these comparative analyses of the 
treatment of gunshot fractures, except in the case of the hip-joint, by 
the three methods, it is not stated whether the amputations or resec- 
tions were primary or secondary. In all secondary amputations and 
resections, which, for aught that appears, may have constituted a ma- 
jority of the whole number, the conservative treatment had been tried 
and had failed, and the deaths which followed ought in justice to be 
charged to conservatism, and not to the operation. As the reports now 
stand, they are of little or of no importance in determining the relative 
value of conservative and operative treatment. 

From the reports of the Confederate army, as published in the Con- 
federate States Medical Journal, we learn that of 221 cases of gunshot 



GUNSHOT FRACTURES. 



521 



fractures of the thigh, treated without amputation or resection, 105 
died and 116 recovered. The shortest period of recovery was 41 days; 
the longest, 255 days ; the average, 104 days. The shortest period of 



Fig. 245. 



Fig. 246. 



Gunshot fracture of thigh. 
Front view. (Author's col- 
lection.) 




Same. Side view. (Au- 
thor's collection.) 



fatal termination was one day; the longest, 185 days; average, 52 
days. Greatest shortening, five inches ; least, half an inch ; average, 
one inch and nine-tenths. 1 

Of 507 amputations for gunshot fractures of the thigh, 250 recov- 
ered. 2 



1 Richmond Med. Journ., Feb. 1866, from Confederate States Med. Journal. 

2 Ibid., January, 1866, p. 52. 



34 



PART II. 



DISLOCATIONS. 



DISLOCATIONS. 



CHAPTEE I. 

GENEKAL CONSLDEKATIONS. 
I 1. General Division and Nomenclature. 

A dislocation is the displacement of one bone from another at its 
place of natural articulation. 

Dislocations may be divided into accidental or traumatic, sponta- 
neous or pathologic, and congenital. 

Our remarks upon the etiology, pathology, symptomatology, prog- 
nosis, and treatment of these injuries must be considered as applicable 
only to accidental or traumatic dislocations, unless the fact is in any 
case otherwise stated. 

Accidental dislocations are those in which the bones have suffered 
displacement in consequence of the application of a sudden force ; and 
surgeons have divided these accidents into Complete and Partial, 
Simple, Compound and Complicated, Recent and Ancient, Primitive 
and Consecutive. 

A complete dislocation is one in which no portions of the articular 
surfaces remain in contact. 

A partial dislocation is one in which the articular surfaces are not 
completely removed from each other. 

A simple dislocation is that form of the accident in which the bone 
has only slid from its articulation, and is accompanied with the least 
or only an average amount of injury to the soft parts or to the bones 
adjacent to the joint. 

A compound dislocation implies that the articulating surface of the 
bone has been thrust through the flesh and skin ; or that in some other 
way a wound has been made which communicates with the joint. 

Complicated dislocation is a term employed by some writers to 
designate a condition wholly differing from a compound dislocation, 
or, in some cases, a condition of extra complication. Thus, a simple 
dislocation may be complicated with a fracture, or with the laceration 
of an important bloodvessel, etc. ; and a compound dislocation may be 
complicated in the same way, and with the addition, perhaps, of exten- 
sive laceration and destruction of integument, muscles, nerves, etc. 

A recent luxation, has taken place within a period of a few days, or, 



526 GENERAL CONSIDERATIONS. 

at most, of a few weeks ; and an ancient luxation has existed daring a 
longer period. The exact point of time at which a dislocation shall be 
called recent or ancient is not fully determined by surgeons, and the 
application of these terms is therefore always somewhat arbitrary. 

A primitive luxation is a luxation in which the bone remains nearly 
or precisely in the position into which it was at first thrown ; while a 
secondary or consecutive luxation is one in which the bone has subse- 
quently, in consequence of the action of the muscles, or from unsuc- 
cessful efforts at reduction, or from some other cause, changed its posi- 
tion sufficiently to entitle the accident to a new designation. Thus a 
primitive dislocation upon the ischiatic notch may become a secondary 
dislocation upon the dorsum ilii, or the reverse. 

I 2. General Predisposing Causes. 

Age. — According to Malgaigne, whose conclusions are based upon 
an analysis of six hundred and forty-three cases, dislocations are very 
rare in infancy, only one having occurred under five years ; but the 
frequency increases gradually up to the fifteenth year, from this period 
more rapidly up to the sixty -fifth year, and from this time onward 
again dislocations become more rare. He has mentioned none after 
the ninetieth year; and the period of greatest frequency is between the 
thirtieth and sixty -fifth year. To this middle period belong four 
hundred and seven of the whole number. 

The inference from this analysis may be thus briefly stated: age, as 
a predisposing cause, is most active in middle life, less active in ad- 
vanced life, and least active of all in early life. 

It is proper, however, to observe that while such statistics may be 
relied upon as indicating the relative frequency of these accidents at 
different periods of life, they cannot be regarded as determining abso- 
lutely the value of age alone as a predisposing cause, since the direct 
or exciting causes may be more active at one period than another, and 
in some measure these latter causes may be, and doubtless are, respon- 
sible for such results. 

Constitution and Condition of the Muscles and Ligaments. — It may 
be stated as a general fact that persons of feeble constitutions, and 
whose muscular systems are much weakened, suffer dislocation from 
slighter causes than those who are in health, and whose muscular sys- 
tems are firm and vigorous: and that a relaxation of the ligaments 
w T hich surround a joint, however this may have been occasioned, pre- 
disposes to dislocation. Thus, a paralyzed and atrophied limb is pre- 
disposed to luxation ; a joint in which the capsule has become stretched 
by effusions, or by violent extension, or weakened by laceration from a 
previous dislocation, or by ulceration, or if in any other way the artic- 
ulation is deprived of these natural protections, we need scarcely say, 
it is thereby rendered more liable to luxation. 

Ball and socket joints, other things being equal, are more liable to 
displacement than ginglymoid; but then much more depends upon the 
relative exposure of the joint than upon its anatomical structure, so 
that the elbow is much more frequently dislocated than the hip; the 



GENERAL SYMPTOMS. 527 

shoulder -joint, however, being, from its position and extent of motion, 
peculiarly exposed, and being also a ball and socket joint, is, of all 
others, most liable to dislocation. 

§ 3. Direct or Exciting Causes. 

These may be classed under two general heads, namely, external vio- 
lence and muscular action. 

External violence operates either directly or indirectly. When a 
person falls upon the knee and dislocates the head of the femur, the 
force is said to have acted indirectly, and this is by far the most fre- 
quent mode of dislocation; but when the blow is received upon the 
upper end of the humerus, and its head is sent into the axilla, it is 
said to have been dislocated by direct violence. 

Muscular action produces a dislocation slowly, as in some cases of 
chronic rheumatism, and then it is called a spontaneous or pathologic 
dislocation; or suddenly, as in the violent spasmodic contractions 
which accompany convulsions; or sometimes by the mere voluntary 
effort of the muscles ; and both of these latter are true accidental luxa- 
tions. 

It is very probable that external force can seldom be regarded as 
the sole cause of a dislocation, but that, in a large majority of cases, 
muscular action consenting with the shock, performs an important role 
in the history of the accident. The limb being driven obliquely across 
its socket by the external violence, is seized by the stretched and ex- 
cited muscles with such vigor as to contribute not a little to the unfor- 
tunate result. Thus it will be found that the same force which is ade- 
quate to the production of a dislocation in the living and healthy 
subject is wholly insufficient to accomplish the same in the dead; and 
a man who is fully intoxicated seldom suffers a dislocation. 

I 4. General Symptoms. 

As fractures are characterized by preternatural mobility and crepi- 
tus, to which may be generally added the circumstance that when 
reduced the fragments will not remain in place without external sup- 
port, so, on the other hand, dislocations are characterized by preter- 
natural rigidity, an absence of crepitus, and by the fact that when 
reduced the bone does not generally require support to maintain it in 
position. 

These three are the usual, and they may be termed the common, 
signs of distinction between fractures and dislocations, but no one of 
them can be alone depended upon as positively diagnostic. Generally, 
when a bone has been dislocated, we shall find the limb in a certain 
position, which is uniform for all dislocations of the same character, 
and almost immovably fixed ; but when the ligaments and muscles 
about the joint have been extensively torn, or the whole body is still 
suffering under the shock, or in any other circumstances where the 
power of the muscles is weakened, this rigidity may give place to ex- 
treme mobility. 



528 GENERAL CONSIDERATIONS. 

True crepitus does not exist without fracture, but is not always 
present in fractures, and there is often a sensation produced in the 
rubbing and chafing of dislocated bones which very much resembles 
certain kinds of crepitus, and by the inexperienced has been often mis- 
taken for it. I allude to the subdued rasping sound or sensation 
which is found generally on the second or third day, and sometimes 
earlier, and which is the result of fibrinous effusions, or, perhaps, in 
some instances, of the mere rubbing of firmly compressed ligamentous 
and cartilaginous surfaces upon each other. The crepitus of a recent 
fracture can be scarcely confounded with this obscure sensation, unless 
it is in some cases of incomplete fracture, or of a fracture situated re- 
mote from the surface, as in the case of the hip ; but a fracture which 
is a few days old, whose surface has become softened by inflammation 
and more or less covered with lymph, and, when the rigidity is great, 
may sometimes deceive the most experienced surgeon, so exactly will it 
be found to imitate the sensations produced by the chafing of an in- 
flamed joint, or of closely approximated fibrous surfaces. 

I have said that a true crepitus does not exist without a fracture ; 
but then a very minute fracture, such as the detachment of a scale of 
bone by the tearing away of a tendon or of a ligament, may produce 
crepitus ; or even the separation of a piece of cartilage may sufficiently 
expose the bone to determine the presence of this phenomenon. These 
are, however, no longer examples of simple dislocation. 

Nor are the two inverse propositions, in relation to the retention of 
the bones in place, invariable in their application. A broken bone, 
well reduced, does not always manifest a tendency to displacement, nor 
does a dislocated limb, when restored to its socket, in all cases maintain 
its position without support. 

The other general signs of dislocation are pain, swelling, and dis- 
coloration. The pain is generally more intense in dislocations than in 
fractures, the expanded end of the bone resting often upon one or more 
large nerves, which usually, with the arteries, approach very near the 
joints, this pressure being also greatly increased by the extreme tension 
of the muscles. Not unfrequently numbness and temporary paralysis 
of the whole limb are the consequences. In other cases the pain is due 
solely to the pressure upon the muscles or to the tension of the muscles, 
or, perhaps, to the tension of the untorn ligaments and capsule. 

Generally the limb is shortened, but in a few cases it is found slightly 
lengthened, while the natural axis of the bone with its socket is always 
changed. If examined early, and before the supervention of swelling, 
the joint end of the displaced bone may be felt in its unnatural posi- 
tion, and a corresponding depression may be discovered in the situation 
of the articulation, especially if the bones are superficial. 

§ 5. Pathology. 

The dissection of recent dislocations produced by external violence 
shows the capsular ligaments more or less torn, and also a rupture of 
some of the lateral and other short ligaments, with a complete rupture 
in most cases of some of the tendons which immediately surround the 



PATHOLOGY. 529 

joint, or of those which are attached to the capsule : the muscles, nerves, 
arteries, etc., through which the bone in its passage has passed, or upon 
which it is found resting, being also contused, stretched, or torn 
asunder. 

This description, however, does not apply to dislocations produced 
by muscular action alone, in a majority of which cases the capsule is 
only stretched, and not torn, and no lesions of other structures are 
necessarily present. 

If the dislocation remains unreduced, the margins of the old socket, 
in the case of enarthrodial articulations, become gradually depressed, 
while the concavity of the socket is filling in with a fibrous or bony 
tissue, until at length the whole of this portion of the joint apparatus 
is nearly or entirely obliterated. This process is generally very slow, 
and may not be consummated until after the lapse of many years. 

At the same time, but with much greater rapidity, the head of the 
bone in its new position, and the soft or hard parts upon which it rests, 
are undergoing certain changes to adapt them to their new relations, 
and calculated in some measure to restore the limb to its normal func- 
tions. If the head of the bone rests upon muscle, the cellular and 
fibrous tissues which enter into the composition of the muscle become 
condensed and thickened, forming a shallow or elongated cup, whose 
margins are attached to the neck or shaft of the bone, and whose walls 
are lubricated with synovia. If it rests upon bone, by a process of 
interstitial absorption a true socket is formed, sometimes deep and 
sometimes shallow, whose edges, receiving additional ossific depositions, 
become lifted so as to form a rim. At the same time the head of the 
bone is undergoing corresponding changes, to adapt itself to the newly 
formed socket ; it is flattened or otherwise changed in form, and in the 
progress of this change its natural secreting and cartilaginous surfaces 
are gradually removed, a porcelaneous deposit taking its place. The 
same kind of hard, polished, ivory-like deposit is found also in those 
portions of the new socket which have been especially exposed to pres- 
sure and friction. Instead of the eburnation, an imperfect fibro-serous 
surface or synovial capsule may be formed. 

I have in my cabinet an example of ancient luxation of the hip-joint 
in which the head of the femur, having rested upon the dorsum ilii, has 
formed a nearly flat but smooth surface — a kind of elevated plateau; 
in other cases I have seen the margins of the new socket so elevated as 
to rest against the neck of the femur, and completely lock it in. 

Consenting with these changes, and in consequence partly of the dis- 
use of the limb, the muscle, and even the bones sometimes suffer a 
gradual atrophy. In some measure these alterations may be due also 
to the pressure of the dislocated bone upon arterial and nervous trunks, 
by which their functions become partially or completely annihilated, 
and their structure even may be wholly obliterated. In consequence 
also of the inflammation which immediately results, we ought not to 
omit to notice that the trunk of a large artery sometimes becomes 
firmly adherent to the capsule or periosteum of a displaced bone, and 
its reduction is attended with imminent danger of laceration and of a 



530 GENERAL CONSIDERATIONS. 

fatal haemorrhage. Numerous instances of this grave accident, espe- 
cially in attempts to reduce old dislocations of the shoulder-joint, are 
upon record. 

I 6. General Prognosis. 

We shall study the prognosis of these accidents to better advantage 
when we come to speak of the individual bones and their various forms 
of dislocation ; but it is proper to state in this place, generally, that 
very few joints, having been once completely displaced from their 
sockets by external violence, are ever so completely restored as not to 
leave some traces of the accident for many years, if not for the whole 
of the subsequent life of the patient, either in the partial limitation of 
their motions, or in the diminished size and power of the muscles of 
the limbs, or in the presence of an occasional arthritic pain : the degree 
and permanence of these sequences depending upon the joint which is 
the subject of the displacement, the extent of the original injury, the 
length of time it has remained unreduced, the means employed in its 
reduction, the health and condition of the patient, with so many other 
contingent circumstances as to preclude the idea of a complete specifi- 
cation. 

If the bone is not reduced, a permanent maiming is inevitable; but 
it is surprising how much time and the intelligent processes of nature 
can eventully accomplish toward a restoration of the natural functions, 
especially when aided by a good constitution and judicious treatment. 
If the symmetry of form and grace of motion are never replaced, the 
value of the limb, for all the practical purposes of life, is not unfre- 
quently completely re-established. 

I 7. General Treatment, 

The first indication of treatment is to reduce the bone. Whatever 
delays may be proper or justifiable in certain cases of fracture, such 
delays are never to be argued in cases of dislocation. The sooner the 
reduction is accomplished the better. For this purpose we resort at 
once to such manipulations or mechanical contrivances as the nature of 
the case demands ; and if these fail, or if at the first they are deemed 
insufficient, we invoke the aid of constitutional means, or such as are 
calculated to diminish the power and antagonism of the muscles. 

Many dislocations may be reduced promptly by manipulation alone; 
which mode is always to be preferred when it will prove sufficient, for 
the reasons that it is generally the least painful to the patient, and the 
least apt to inflict additional injury upon the muscles and ligaments. 

A person wholly unacquainted with anatomy or surgery may occa- 
sionally succeed in reducing a dislocated limb ; indeed it frequently 
happens that the patient himself, by mere accident in getting up or in 
lying down, accomplishes the reduction ; and even in a very large ma- 
jority of cases, force and perseverance will finally succeed by whomso- 
ever they may be employed ; but the observing student of surgery will 
soon discover the difference between accident and brute force on the 



GENERAL TREATMENT. 531 

one hand, and intelligent manipulation on the other. The charlatan 
bone-setter does not often allow himself to fail, unless the courage of 
his patient gives out, or he ignorantly supposes the reduction to be 
effected when it is not ; but his success, achieved through great and 
unnecessary suffering, is often obtained, also, at the expense of the limb. 
While the surgeon, whose knowledge of anatomy enables him to under- 
stand in what direction the muscles are offering resistance, and through 
what ligaments the head of the bone must be guided, lifts the limb 
gently in his hands, and the bone seeks its socket promptly and with- 
out disturbance, as if it needed only the opportunity that it might 
demonstrate its willingness to return. 

We must understand not only what muscles and ligaments antag- 
onize the reduction, if w r e w T ould be most successful, but also what 
muscles, by being provoked to contraction, will themselves aid in the 
reduction. In short, to become expert bone-setters in the department 
of dislocations, one must possess a complete knowledge of the physiog- 
nomy or the external aspect of joints, acquired only by repeated and 
careful examinations, he must be familiar with the anatomy and func- 
tions of the muscles, he must understand thoroughly the ligaments, he 
must have experience, tact, and fertility of resource. 

Without these qualifications a man will do better never to under- 
take to treat dislocations, since he is constantly liable to mistake frac- 
tures for dislocations, and dislocations for fractures ; he will submit a 
sprained wrist to violent extension, under the conviction that the joint 
is displaced ; he will mistake natural projections for deformities, and 
fail to recognize the real deformity when it actually exists ; he will 
leave bones unreduced, fully believing that they are reduced ; and he 
will, all in all, within a few years, accomplish vastly more evil than 
he can ever do good. Let a man practice any other branch of surgery 
if he will, without experience or scientific knowledge, but he must 
not attempt to reduce dislocated bones. The most learned and the 
most skilful we shall find falling into error, embarrassed by the un- 
certainty of the diagnosis, or successfully resisted by the power of the 
opposing agents; what then can be expected of those who are both 
ignorant and inexperienced, but failures and disasters? 

As a means of disarming the muscles, or of placing them off their 
guard, we often practice successfully the diversion of the mind of the 
patient. ' At the very moment that the limb is moved or extension is 
made, a question is addressed to him, or he may be suddenly surprised 
by some unexpected intelligence. 

Extension and counter-extension, made with our own hands or with 
the hands of assistants, constitute the second resort where manipula- 
tion alone has failed. The surgeon seizing upon the limb firmly with 
his hands, makes the extension, while the assistants make the counter- 
extension ; or, instead of grasping the limb directly, the operator may 
use for this purpose circular and longitudinal bandages, or the bandage 
or handkerchief tied in the form of the clove-hitch. Extension is thus 
applied in connection with manipulation, aided, perhaps, by direct 
pressure upon the head of the displaced bone. Failing in this, we 
employ some one of the various mechanical contrivances which, whila 



532 



GENERAL CONSIDERATIONS. 



Fig. 247. 



they are capable of exerting much more power, possess also the im- 
portant advantage of operating gradually and steadily, by which mode 

the resistance of the muscles is always more 
speedily and more completely overcome. 

For this purpose surgeons employ gener- 
ally, in the case of the large limbs, the com- 
pound pulleys, or the simple rope windlass, 
which latter is thus described by Dr. Gilbert, 
of Philadelphia : " Place the patient, and 
adjust the extending and counter-extending 
bands as for the pulleys; then procure an 
ordinary bed-cord or a wash-line, tie the ends 
together and again double it upon itself, pass 
it through the extending tapes or towels, 
doubling the whole once more, and fasten the 
distal end, consisting of four loops of rope, to 
a window-sill, door-sill, or staple, so that the 
cords are drawn moderately tight; finally, 
pass a stick through the centre of the double 
rope, then by revolving the stick as an axis 
or double lever, the power is produced pre- 
cisely as it should be in such cases, viz., slow- 
ly, steadily, and continuously." 

Jarvis's adjuster, although very complex, 
possesses some advantages over the pulleys, 
which may, perhaps, entitle it to the preference in a few cases. 

Among the constitutional means, ether and chloroform occupy the 
first rank ; indeed they are, at the present day, almost the only means 
of this class to which surgeons resort, and their value in this point 




Clove-hitch. (From Erichsen.) 



Fig. 248. 





Compound pulleys, and ring to which one end of the pulley-rope is fastened. 



of view can scarcely be over-estimated. Only when some unusual 
circumstance or condition of the patient forbade the use of an anaes- 
thetic, would the surgeon return to the ancient practice of bleeding 
ad deliquium, of prostrating the system with antimony, or to the use 
•of those vastly less efficient agents, opium and the warm bath. 



DOUBLE OR BILATERAL DISLOCATION. 533 



CHAPTEE II. 

DISLOCATIONS OF THE LOWER JAW (TEMPORO-MAXILLARY). 

There are two principal forms of this dislocation, namely, the 
double or bilateral dislocation, and the single or unilateral ; in both of 
which the direction of the displacement is forwards. To these there 
has been added one example of an outward displacement accompanied 
with a fracture. 1 

\ 1. Double or Bilateral Dislocation. 

This form of dislocation of the lower jaw is much the most frequent, 
being met with in about two out of every three cases. It appears also 
to occur oftener in women than in men, and usually between the twen- 
tieth and thirtieth year of life. In infancy and extreme old age it is 
exceedingly rare; yet Sir Astley Cooper mentions a case in which 
" two boys " being at play, one had an apple thrust into his mouth, 
producing a double dislocation ; and Nelaton saw the same accident in 
an old man of seventy-two years, who was toothless. 

This comparative immunity in youth and old age has been ascribed 
to certain peculiarities in the form of the jaw at these periods of life. 
Nelaton attributes its more frequent occurrence in middle life to the 
great length and strong anterior inclination of the coronoid process. 

In a majority of cases the direct or immediate cause has seemed to 
be muscular action alone. Malgaigne found this cause to prevail in 
twenty-five out of forty cases ; and of the twenty-five cases fifteen 
were occasioned by gaping, five by convulsions, four by vomiting, and 
one by rage. Dr. Physick, of Philadelphia, found both condyles dis- 
located in a woman in consequence of the violent gesticulation of her 
jaw while scolding her husband. But in a more remarkable case still, 
this surgeon found the jaw dislocated after recovery from a profuse 
salivation, and of the cause of which, or the time of its occurrence, the 
patient, a young girl, could give no account. Dr. Physick made sev- 
eral ineffectual attempts at reduction, and only succeeded at last after 
he had made her completely intoxicated with ardent spirits. 2 

Dr. E. Andrews, of Michigan, found both condyles dislocated by a 
lobelia emetic. The patient had often taken these emetics before, and 
had frequently experienced a sensation "of catching" at the joint, but 
the jaw had always until this time resumed its position spontaneously. 3 

Among the causes from outward violence, the introduction of some 

1 Robert, Journal de Chir., 1844. 

2 Physick, Dorsey's Elements of Surgery, vol. i, p. 202. Philadelphia, 1813. 

3 Andrews, Peninsular Journ. Med., vol. iii, p. 101. 1855. 



534 DISLOCATIONS OF THE LOWER JAW. 

foreign body into the mouth, and the extraction of teeth, occupy the 
most important place. In fifteen cases seven were from the former 
and six from the latter cause. 

My former pupil, Dr. A. W. Gilbert, has related a case which came 
under his own observation, produced by a similar cause. During his 
apprenticeship with Dr. Parsons, a dentist, he was requested to insert 
a set of teeth for a young man residing in Cattaraugus Co., N. Y., and 
while opening his mouth to take an impression of his gums, he dislo- 
cated " both condyles forwards, under the zygomatic arches ;" but so 
perfectly were the muscles relaxed, that he immediately reduced them, 
without the least difficulty, by placing his thumbs as far back as pos- 
sible upon the molar teeth, depressing the back part of the jaw, and 
at the same moment elevating the chin. 1 

Prof. James Webster, of Rochester, N. Y., dislocated the jaw of a 
lady while attempting to pry out a root of one of the molars. 

Pathology. — In order that we may better understand the pathology 
of this accident, it will be proper to say a few words in relation to the 
anatomy of the temporo-maxillary articulation and the other parts 
concerned in the dislocation now under consideration. 

The articulation is formed by the condyloid process of the inferior 
maxilla and the glenoid fossa of the temporal bone, in front of which 
fossa, and at the root of the zygomatic arch, is a slight elevation, called 
the articular eminence. Between the joint surfaces, both of which are 
covered with cartilage of incrustation, is placed an interarticular car- 
tilage, which divides the joint into two cavities, one corresponding to 
the condyle of the inferior maxilla, and the other to the glenoid fossa, 
each of which is furnished with a distinct synovial membrane. 

Properly there is but one ligament — namely, the external lateral — 
which passes from the outer surface of the articular eminence to the 
corresponding surface of the neck of the condyle. What is called the 
internal lateral ligament arises from the apex of the spinous process of 
the sphenoid bone, and is inserted into the margin of the dental fora- 
men, and has therefore no immediate connection with the articulation, 
although it tends to strengthen the joint. The same is true of the 
stylo-maxillary ligaments. 

The lower jaw is drawn upwards, or closed upon the upper jaw, by 
the action of the temporal, masseter, and internal pterygoid muscles ; 
it is drawn downwards by the action of the digastricus, mylo-hyoideus, 
and genio-hyoglossus muscles ; forwards by a few fibres of the masseter 
and by the external pterygoid muscles ; and laterally by the alternate 
action of the external and internal pterygoid muscles. 

When the mouth is open to its utmost extent, the maxillary condyle 
rises upon the articular eminence until it rests upon its very summit. 
Indeed, it is probable that in most persons it advances rather in front 
of the centre of the eminence ; so that in order to become actually 
dislocated it only needs that the capsule shall be somewhat relaxed, or 
that it shall actually give way in front, when the condyles slide for- 

1 Gilbert, Thesis on Dislocation of the Inf. Max. University of Buffalo, 1858. 



DOUBLE OR BILATERAL DISLOCATION. 



535 



wards and occupy a position directly in front instead of behind this 
eminence. 

It is easy to comprehend how the combined action of the two external 
pterygoid muscles, with a portion of the fibres of the masseter, may 
alone produce the dislocation when the mouth is wide open, and espe- 
cially when, in consequence of a slight blow upon the chin, the anterior 
portion of the capsule becomes 
lacerated; for it must be noticed 
that the ascending ramus, with 
its prolonged condyloid process, 
constitutes a lever of the first 
kind, in which the temporal 
muscle, attached to the coronoid 
process, the masseter, and even 




Double dislocation of the inferior maxilla. 



the mastoid process, constitute 
the fulcrum, the anterior portion 
of the capsule, the weight, and 
the force acting against the front 
of the chin, the power. 

In this position of the condyle, 
drawn upwards and forwards by 
the action of the pterygoid and 
temporal muscles, the chin descends toward the neck, and the coronoid 
process rests against the back of the superior maxilla, or against the 
malar bone at the point of its junction with the upper maxillary. The 
temporal, masseter, and internal pterygoid muscles are very much upon 
the stretch, if not more or less lacerated. 

Symptoms. — The mouth is widely open and the jaw nearly immov- 
able. It has been noticed generally that, by pressure, the chin may 
be slightly depressed, but that, owing probably to the pressure of the 
coronoid process against the body of the upper maxilla, or against the 
malar bone, it is generally impossible to elevate the jaw in any degree 
whatever. 

The jaw is also slightly advanced ; a depression, covering a consid- 
erable space, exists between the auditory canal and the posterior mar- 
gin of the condyle. A slight fulness is observed in the temporal fossa, 
and also upon the side of the cheek in the region of the masseter muscle. 

Ordinarily the patient suffers considerable pain, but not always, 
from the pressure of the condyles upon the branches of the temporal 
nerves. There is a constant flowing of the saliva from the mouth ; the 
patient is unable to articulate, and even deglutition is performed with 
great difficulty. 

Prognosis. — When the dislocation remains unreduced, the lower jaw 
gradually approximates the upper, and its anterior projection sensibly 
diminishes, the saliva ceases to dribble from the mouth, deglutition 
and speech are restored, mastication is performed with considerable 
ease, and, in short, the patient comes at length to experience no great 
inconvenience from the displacement. 

Robert Smith relates the case of a woman whose lower jaw was dis- 
located during an epileptic convulsion. She was at the time in one of 



536 



DISLOCATIONS OF THE LOWER JAW. 



Fig. 250. 




the metropolitan hospitals, but the accident was not noticed by the 
surgeons, and it remained ever afterwards unreduced. At the end of 

a year she could close the lips per- 
fectly, but was able to open the mouth 
only to a limited extent; the teeth of 
the lower jaw remained advanced, the 
involuntary flow of saliva had ceased, 
and the faculty of speech had been 
regained. 1 In Professor Webster's 
case, to which I have before referred, 
although the jaw was immediately 
and easily reduced, after the lapse 
of several years, when I saw the 
lady, she still complained that it hurt 
her whenever she ate, and that she 
often felt the condyles slip in their 
sockets. 

Reduction has been accomplished 
by Physick in the case already related 
after the lapse of several weeks ; Sir 
Astley Cooper reduced a double dis- 
location after a month and five days, 
which had been overlooked by the 
surgeon in attendance; 2 and Donovan 
succeeded after ninety-five days. 3 
Treatment. — Reduction may generally be accomplished with ease in 
cases of recent luxation, in the following manner : The patient being 
seated upon the floor with his head between the knees of the operator, 
a couple of pieces of cork, gutta-percha, or pine wood are placed as 
far back between the molars as possible, when the surgeon seizing 
upon the chin draws it steadily upwards, taking care not to draw it 
forwards at the same time, since by this movement he would resist 
the action of the muscles which naturally tend to restore it to place 
whenever the condyloid processes are lifted sufficiently from the zygo- 
matic fossae. Many surgeons prefer to sit or stand in front of the 
patient, and depress the condyles by means of the thumbs placed inside 
of the mouth and upon the tops of the molars. If the thumbs are 
used in this way, it would be well to protect them with a piece of 
leather, or to slip them off from the teeth suddenly when the condyles 
are gliding into their places, as the muscles sometimes close the mouth 
with sufficient violence to bruise severely anything which might at 
this moment be interposed between the teeth. 

The method practiced by Ravaton, of simply lifting the chin gradu- 
ally and forcibly toward the upper jaw, was essentially the same, but 
far less efficient ; for although he placed nothing between the molars 
to serve as a fulcrum, the backmost teeth themselves must in some 



Double dislocation of the inferior maxilla. 



1 Robert Smith, on Fractures and Dislocations. Dublin, 1854, p. 288. 

2 Sir Astley Cooper, on Disloc. and Frac, Amer. ed., p. 316. 

3 Donovan, Amer. Journ. Med. Sci., Oct. 1842, p. 470; from Dublin Med. Press, 
May 25, 1842. 



SINGLE OR UNILATERAL DISLOCATIONS. 537 

degree perform this service whenever the lower jaw being dislocated 
and drawn upwards, the chin is forcibly approximated toward the 
upper. 

In other cases it has been found necessary first to disengage the 
coronoid process, by depressing the chin gently, and then pressing 
backwards in the direction of the articulation ; a method which would 
certainly deserve a trial in case of the failure of that first described. 
This was the method practiced by Hippocrates. 

A more effectual expedient, however, consists in reducing one side 
at a time ; taking good care always that the side first reduced is not 
reluxated while the attempt is being made to reduce the other, a thing 
which happened in one of the cases treated by Sir Astley Cooper, and 
has happened many times in the practice of other surgeons. 

Finally, if all other expedients fail, we ought not to hesitate to 
resort to anaesthetics, nor indeed could any objection exist to their em- 
ployment at any period of the treatment, were it not that in a large 
majority of cases the reduction is effected so easily and promptly as to 
render their employment wholly unnecessary. 

After the reduction is accomplished, it will be a matter of wise pre- 
caution to sustain the jaw by a double-headed bandage passed under 
the chin, and secured upon the top of the head, so as to prevent the 
mouth from being accidentally opened too far, especially during sleep, 
since experience has shown that a tendency to a reproduction of the 
dislocation remains for some time. It will be prudent to continue 
these measures of protection for at least one week ; after which the 
danger of anchylosis should be borne in mind, and the extent of pas- 
sive motion should be gradually and cautiously increased. In illus- 
tration of this tendency to reluxation, Malgaigne refers to the case 
mentioned by Putegnat of a woman whose jaw for many years became 
luxated at least once a month ; but she was always able to reduce it 
herself. 

§ 2. Single or Unilateral Dislocations. 

The causes of this accident are in general the same as those which 
produce double dislocations, and it occurs most often in middle life. 
Tartra has seen one exceptional example in a child only fifteen months 
old, and Levison saw a case in an old man who had lost all his teeth. 1 

Symptoms. — The mouth is open, but not so widely as in double dis- 
location ; the jaw is nearly immovable; the teeth are advanced; the 
condyloid process can be felt in front of the articular eminence, leav- 
ing a depression in its natural situation, and the coronoid process is 
more prominent than in the bilateral dislocation. 

It will be remembered that we have already pointed out an impor- 
tant diagnostic mark between a fracture of the neck of the condyloid 
process and a dislocation of one condyle. In the latter the chin in- 
clines to the opposite side, while in the former it falls toward the side 
upon which the accident has occurred. According to Hey, this lateral 

1 Levison, Boston Med. and Surg. Journ., vol. xxxiv, 1846, p. 388, from London 
Lancet. 

35 



538 DISLOCATIONS OF THE LOWER JAW. 

deviation of the chin is not always present in dislocations; and Robert 
Smith mentions one case in which the surgeon was misled by this cir- 
cumstance so far as to attempt a reduction upon the left side when the 
dislocation was upon the right. 

Treatment. — The same rules of treatment which we have established 
for dislocations of both condyles will be applicable to the single dislo- 
cations, with only such modifications as will be naturally suggested to 
the surgeon. 

In the case mentioned by Levison, the dislocation was constantly 
recurring upon the left side ; and it was especially liable to happen 
when just awakening from sleep. " He would then pull his jaw, press 
it backwards, when, after about half an hour's work, bang it seemed 
to go, and all was right again." This old gentleman was finally re- 
lieved of these annoyances by a band fastened under the chin. In 
such a case, an apparatus constructed after the same plan as my lower- 
jaw fracture apparatus might perhaps serve a useful purpose. 

I 3. Conditions of the Jaw simulating Luxations. 

There is a condition of the temporo-maxillary articulation called by 
Sir Astley Cooper " subluxation of the jaw," in which it is assumed 
that the condyles slip before the anterior margins of the interarticular 
cartilages, and thus for the time render the jaw immovable. No posi- 
tive evidence, however, has ever been presented, either by Sir Astley 
or others that any such derangement of the joint apparatus does actu- 
ally take place, the opinion being based, not upon dissections, but only 
upon the symptoms which are known to accompany the accident. It 
is quite probable that this explanation of the phenomenon in question 
is the true one, yet it is not impossible that, in some rare cases it has no 
relation whatever to the interarticular cartilages, but that it indicates 
a true subluxation of the inferior maxilla upon the zygomatic emi- 
nences. 

It occurs mostly in young people, and in those of a feeble or scrofu- 
lous diathesis. Relaxation of the capsule, ligaments, and muscles 
about the joint may, therefore, be regarded as the principal predispos- 
ing cause. The exciting causes are generally yawning, or biting upon 
some very hard substance. 

The symptoms are a sudden arrest of the motions of the jaw, with 
the mouth about half open, the arrest of motion being accompanied or 
preceded generally with a sensation of slipping in one of the articula- 
tions. The chin is slightly inclined to the opposite side. The condyle 
may be felt somewhat advanced in its socket, and while it remains in 
this position the patient experiences some pain. 

In most cases the condyle resumes its place spontaneously, or after a 
slight lateral motion of the jaw; but at other times it requires some 
little manual force to replace it. 

I have myself, during several years of my early life, while pursuing 
my studies at college, experienced this accident many times. It was 
peculiarly prone to occur in the morning, and it became necessary that 
I should eat with some care at my first meal. Sometimes the locking 



CONDITIONS OF THE JAW SIMULATING LUXATIONS. 539 

of the jaw was upon the right and sometimes upon the left side ; it was 
always slightly painful. Generally the condyle was made to fall into 
place by a voluntary lateral motion of the jaw, but occasionally I was 
obliged to press gently against the chin with my hand. I never adopted 
any measures to remove the predisposition, but as I became older the 
annoyance gradually ceased. 

Benevoli, in a dissertation published at Florence, Italy, in the year 
1747, describes another condition very analogous to this which Ave have 
now described, but which evidently depended upon a contraction of the 
muscles. A priest having opened his mouth very widely in gaping, 
found himself unable to close it. A surgeon who was called diagnos- 
ticated a dislocation of the jaw, and attempted to reduce it, but failing, 
Benevoli was called, who observing " that the jaw was not absolutely 
immovable, that the articulations were not separated, and that the chin 
did not incline outwards or toward the sternum," concluded that it was 
only a contraction of the depressing muscles. He therefore prescribed 
fomentations and oily unctions. The same night the temporal muscles 
had acquired the size of a couple of eggs, from contraction, but the 
next day the patient could shut his mouth, and by the following day 
the tumefaction of the temporal muscles had also disappeared, and the 
restoration of the functions of the mouth was complete. 

Malgaigne, to whom I am indebted for the above case, relates two 
others, one in the person of the surgeon Mothe, and the other in a 
young man who was suffering from paralysis and spasmodic contrac- 
tions of the muscles. Mothe observes that it had occurred to him very 
often, and that it still continued to happen sometimes, that when he 
gaped pretty widely, the genio-hyoid and mylo-hyoid muscles con- 
tracted with so much force as to render it impossible for him to close 
his mouth ; these muscles being thus in a s+ate of cramp, their bellies 
became hard under the chin, and so painful that he was obliged imme- 
diately to press upwards against the under surface of the chin in order 
to oppose their action. This condition would last from one to three 
minutes, and was relieved, generally, by frictions made with the hand 
over the contracted muscles. Sometimes he actually believed that the 
lower jaw was dislocated, although the result always convinced him 
that it was not. 

Treatment. — In most or all of the cases of this peculiar derangement 
of the temporo-maxillary articulation, which have come under my 
notice, a spontaneous cure has been soon effected. It will be proper, 
however, in all cases, to instruct the patient to avoid using the jaw in a 
manner to produce the sensation of slipping; and if the general health 
is impaired, to adopt suitable measures to improve his condition. Cold 
water affusions to the side of the face and jaw would seem also to be 
rational measures, and I have generally recommended their use. 



540 DISLOCATIONS OF THE SPINE. 




CHAPTER III. 

DISLOCATIONS OF THE SPINE. 

Delpech and Abernethy denied the possibility of a dislocation' of 
the spine, either in the cervical, dorsal, or lumbar region, without the 
concurrence of a fracture. 

Says Sir Astley Cooper : " I have never witnessed a separation of 
one vertebra from another through the intervertebral substance, without 
fracture of the articular processes ; or, if those processes remain un- 
broken, without a fracture through the bodies of the vertebrae." He 
would not, however, be understood to deny the possibility of a disloca- 
tion of the cervical vertebrae, their articular processes being placed more 
obliquely than those of the other vertebrae. 

The accident is, no doubt, exceedingly rare, at least without the com- 
plication of a fracture, and it is not improbable that the actual number 
is smaller than the reported examples would indicate. Those who 
make autopsies do not always perform their duties with that exact 
fidelity which might be necessary to determine so nice a point as a 
fracture of an oblique process, and it is quite likely that the circumstance 
may have been overlooked in some cases ; but a considerable number 
of well-authenticated examples of simple dislocations of cervical verte- 
brae have accumulated within the last fifty years. The reported exam- 
ples of simple dislocations of the other vertebrae are not so numerous, 
nor as well attested. 

The causes are in general the same with those which produce frac- 
tures of the vertebrae, such as falls upon the head, feet, or back, and 
violent flexions of the spine backwards or to the one side or th^ other. 

Several examples are recorded of "spontaneous" dislocations, the 
result of some morbid changes in the bones or in the ligaments of the 
spinal column ; which accidents seem to belong more properly to gen- 
eral treatises upon surgery. 

The symptoms, also, partake of the same general character with 
fractures ; the accident being accompanied with more or less complete 
paralysis of those portions of the body which receive their nervous 
supply from below the point at which the dislocation has occurred; 
the spinal column presenting at the seat of displacement an angular 
projection or some form of irregularity ; and the distortion being at- 
tended with pain, especially when an attempt is made to move the 
body. 

In very many cases the symptoms are so nearly like those presented 
in a case of fracture, that the diagnosis is rendered exceedingly difficult. 
The presence or absence of crepitus may aid in the diagnosis, and yet 
it is well understood that this symptom is often absent in simple frac- 
tures, and that it may be present in all those examples of dislocation 



DISLOCATIONS OF THE LUMBAR VERTEBRA. 541 

which are accompanied with a fracture of an oblique process, or of any 
other portion of the vertebra?, which class of examples constitutes a 
large majority of the whole number. 

There is usually present, however, in the dislocation, whether partial 
or complete, a peculiar fixedness or rigidity of the spine, which serves 
to distinguish this accident from a fracture of the spine as plainly as 
the preternatural rigidity of the limb in dislocations of the long bones, 
serves to distinguish these accidents from fractures of the same bones. 
The head or upper portion of the spinal column is bent forwards, or 
backwards, or more commonly to one side, and in this position it re- 
mains immovably fixed until the reduction is accomplished. Some- 
times, also, the surgeon may feel distinctly the lateral deviation of the 
spinous process, and, in the neck, the transverse processes become an 
important guide in the diagnosis. 

After these few general remarks, I shall proceed to speak of disloca- 
tions of the spine in the same order in which I have treated of fractures 
of the spine. 

\ 1. Dislocations of the Lumbar Vertebrae. 

Sir Astley Cooper plainly intimates that he does not believe a dislo- 
cation can occur in either the dorsal or liimbar region without the ^-— 
concurrence of a fracture, and Boyer affirms positively that it is " en- 
tirely impossible." 

Without wishing ourselves to insist upon the actual impossibility of 
these accidents, we are prepared to affirm that no well-authenticated 
case has yet been reported ; at least of a complete dislocation, unac- 
companied with a fracture of the articulating apophyses. We can 
even conceive it possible that a lumbar vertebra may be dislocated 
forwards or backwards, and that a dorsal vertebra may be dislocated 
laterally, without a fracture ; yet we hardly think either of these events \ 
probable. What we urge, however, is that no evidence appears to be j 
furnished that such a dislocation has actually occurred. 

Cloquet mentions the case of a " tiler " who fell from the roof of a 
house backwards, and dislocated one of the lumbar vertebra?. This 
patient lived many years after the accident, and at the autopsy it was 
found that the second lumbar vertebra had been luxated to the right 
by a movement of rotation about the left articular process, the two 
oblique processes of the left side preserving their connection, while 
those of the right were separated quite half an inch. The right verte- 
bral plate was broken, and the canal of the vertebra was thus thrown 
open and widened. 1 

Dupuytren says that a man was crushed by the falling of a bank of 
earth upon his loins, when in the act of bending forwards. On the 
third day he was brought to Hotel Dieu, when it was observed that 
his lower extremities were completely paralyzed ; and that there ex- 
isted in the upper part of the lumbar region a hard tumor, by pressure 
upon which a crepitus was manifest. A second tumor could be dis- 

1 Cloquet, Malgaigne, from Journ. des DifTbrmites de Mnison , torn, i, p. 453. 



542 DISLOCATIONS OF THE SPINE. 

tinctly felt in front through the abdominal parietes, and the length of 
the spine was evidently diminished. This man died on the sixth day 
from a gradual asphyxia. When the body was examined it was found 
that the last dorsal and first lumbar vertebrae had been pushed for- 
wards more than one inch, lacerating the spinal marrow, breaking the 
transverse and oblique processes of the last dorsal and first two lumbar 
vertebra?, and tearing off a small fragment of the body of one of the 
vertebrae where the intervertebral substance adhered to it. 1 

These are all the cases of dislocation of the lumbar vertebrae of 
which I am able to find any record. Both were accompanied with 
fractures. In neither case was any attempt made to reduce the dislo- 
cations. In the second, it is scarcely probable that any means could 
have been employed which would have succeeded in restoring the 
bones to their places ; nor is it probable that if the bones had been re- 
stored to place, the patient would have survived the accident a day 
longer, probably not so long. The cord was greatly lacerated, and 
the diaphragm torn up and displaced, rendering a recovery almost im- 
possible. 

In the first example, where the dislocation was less complete, and 
the complications less grave, could reduction have offered any reason- 
able chance for relief? By extension, combined with a movement of 
rotation in a direction opposite to that in which the displacement had 
taken place, it is possible that a reduction might have been accom- 
plished. The attempt certainly would have been justifiable; but since 
the man lived " many years " without the reduction, it is doubtful 
whether the result of a reduction would have been more fortunate. 

I 2. Dislocations of the Dorsal Vertebrae. 

Malgaigne enumerates twelve examples of dislocations of the dorsal 
vertebrae. I have found reported by American surgeons, at dates too 
recent to have been included in his analysis, two other examples ; but 
of this number only three are claimed to have been simple dislocations, 
unaccompanied with fracture. One of the fourteen was a dislocation 
of the fifth dorsal vertebra upon the sixth, one of the eighth, two of 
the ninth, five of the eleventh, and five of the twelfth ; the relative 
frequency of their occurrence in the different vertebrae corresponding 
with the observation of Weber, as to the points of the spinal marrow 
which allow of the greatest freedom of motion, and are consequently 
most liable to dislocations. The direction of the displacement in ten 
cases was observed to be six times forwards, twice backwards, and 
twice to the one side. 

Two of those which were unaccompanied with fracture, occurring 
respectively in the tenth and sixth dorsal vertebrae, were examples of 
a dislocation forwards, and the third, belonging to the ninth vertebra, 
was a dislocation backwards. A lateral luxation without fracture has 
not been recorded. It is worthy of remark, also, that these three exam- 

1 Dupuytren, Injuries and Dis. of Bones, Syd. ed., p. 340. 



DISLOCATIONS OF THE DORSAL VERTEBRJ1. 543 

pies, being all which our science up to this moment possesses, have 
happened in the experience of the same surgeon. 1 

A moment's consideration of the anatomy of these processes will 
render it apparent that even a partial luxation forwards without a frac- 
ture of the oblique apophyses is impossible, and that in the direction 
backwards the luxation can only occur to the extent of about one- 
quarter of an inch, constituting only a species of articular diastasis, 
without breaking off the articulating apophyses of the lower corre- 
sponding vertebra. The first two examples, therefore, notwithstanding 
they have been received without question by Malgaigne, I shall un- 
hesitatingly reject. The third, which alone carries evidence of its 
having been correctly reported, and which was only a partial disloca- 
tion, is related as follows: "A mason having fallen from a height in 
such a manner as that the lower part of his back struck upon the angle 
of the upper step of a ladder, died on the following day. After death 
it was observed that the spinous processes of the dorsal vertebrae were 
prominent down to the tenth ; and that the tenth process with all of the 
processes below were depressed. It was also noticed that this depres- 
sion, very marked when the trunk was thrown backwards, gradually 
diminished and finally disappeared altogether when the body was bent 
forwards. On removing the soft parts it was found that the ligaments 
were extensively torn asunder and detached, so as. to permit the articu- 
lating apophyses of the tenth vertebra to be carried into contact with 
the back of the ninth. The spinal marrow had undergone no visible 
alteration." 2 

Malgaigne thinks he has once observed the same thing on a living 
subject, and that by simply bending the body forwards he accomplished 
the reduction and effected a perfect cure, except that a slight curvature 
remained at the point of injury. 

Among the cases reported as having been complicated with fracture, 
the following example, reported by Dr. Graves, of New Hampshire, to 
Dr. Parker, of this city, possesses unusual interest : 

On the second day of January, 1852, a man, set. 25, was struck on 
the back while in a stooping posture by a falling mass of timber, causing 
a dislocation of the last dorsal upon the first lumbar vertebra. His 
lower extremities were completely paralyzed, and priapism continued 
for several hours. The surgeon determined to make an attempt at re- 
duction, and for this purpose he placed the patient upon his face, and 
secured a folded sheet under his armpits and another around his hips, 
directing four strong men to make extension and counter-extension by 
these sheets. Chloroform was administered, and when the patient was 
completely under its influence the extending and counter-extending 
forces were applied, and in a few minutes the vertebrae glided into place 
with a distinct bony crepitus. The restoration of the line of the ver- 
tebral column was found to be nearly but not quite perfect. 

On the sixteenth day he began to have slight sensations in his feet, 
and at the end of six or eight weeks he was able to control the evacu- 

1 Melchiori, Gaz. Medica, stati sardi, 1850. 2 Melchiori, loc. cit. 



514 DISLOCATIONS OF THE SPINE. 

ations from the bladder and rectum. Several months later he had 
recovered so completely as to walk with only the aid of a cane. 1 

I know of only one similar case. Rudiger has published an account 
of a dislocation obliquely backwards and to the right side, which 
occurred at the same point in the spinal column. The subject was a 
musketeer, who had been struck upon his back by a falling wall which 
he was endeavoring to pull down. Rudiger laid him upon his belly, 
and by the assistance of others he was able, but not without causing 
pain, to reduce the bones. Immediately, however, when the extension 
was discontinued, the action of the muscles caused the displacement to 
recur. The surgeon then directed four men to make extension, while 
another man retained the bones in place by pressing upon them with 
his hands. After several hours this method of pressure was replaced 
by a board underlaid with compresses and sustaining a weight of more 
than fifty livres. On the following day it was found sufficient to bind 
compresses over the projecting bone, and in this condition the patient 
remained fifteen days; during all of which time he lay upon his belly 
with his shoulders more elevated than, his pelvis. On the twentieth 
day he could lie upon his back, and in about six weeks he was so com- 
pletely restored as to be able to pursue his trade as before! 2 This is 
certainly a very extraordinary case, whether considered in reference to 
the means employed to restore the bones to place, or to its results ; 
and if the statements are to be received at all, it must be with some 
hesitation and allowance. 

On the other hand, we are able to present at least one example in 
which, although no reduction has been accomplished, the patient has 
survived the accident many years ; yet it must be admitted that his 
recovery is far from having been as complete as in the two cases just 
mentioned. 

Joseph Stocks, set. 11, in the spring of 1826, was crushed under the 
body of an ox-cart in such a manner as to produce a dislocation of the 
last dorsal from the first lumbar vertebra, causing immediately almost 
complete paralysis of all the parts below. This young man was seen 
by Dr. Swan, of Springfield, Mass., in the summer of 1834, at which 
time he was occupied as a portrait-painter. His lower extremities 
remained paralyzed and of the same size as at the time of the receipt 
of the injury. He was unable to sit erect, owing to the mobility of 
the spine at the seat of dislocation, and he had therefore lain constantly 
upon his side. The upper portion of his body was well developed, and 
his intellectual faculties were of a high order. 3 

It is not, however, with a life of perpetual deformity that the two 
examples of reduction already described are to be contrasted. A result 
so fortunate as this, where the bones remained unreduced, is unique; 
in all the other cases reported the patients died miserably after periods 
ranging from a few days to one year or a little more. 

Charles Bell has related the case of an infant who was run over by 

1 Graves, N. Y. Journ. Med., March, 1852, p. 190 

5 Rudiger, Journ. de Clrir. de Desault, torn, iii, p. 59. 

3 Swan, Bost. Med. and Surg. Journ., vol. xxii, p. 102, March, 1840. 



OF THE SIX LOWER CERVICAL VERTEBRA. 545 

a diligence, and who died thirteen months after the accident. On 
examination after death, the last dorsal vertebra was found to be 
completely luxated backwards and to the left, upon the first lumbar 
vertebra. 1 

With these facts before us, I think we cannot hesitate, when the 
nature of the accident is fully made out, and especially when the dis- 
location has occurred in the lower dorsal vertebrae, to attempt the 
reduction by forcible extension, united with judicious lateral motion, 
or with a certain amount of direct pressure upon the projecting spines. 

I 3. Dislocations of the Six Lower Cervical Vertebrae. 

It is much more common to meet with simple luxations of the ver- 
tebrae of the neck uncomplicated with fractures, than of either of the 
other vertebral divisions. This is doubtless owing to the greater extent 
of motion which their articulating surfaces enjoy. 

They may be dislocated forwards or backwards. The forward lux- 
ation may be complete or incomplete; with both sides equally advanced 
(" bilateral" of Malgaigne), or one of the articulating apophyses may 
be dislocated forwards, holding the opposite apophysis in its place 
("unilateral" of Malgaigne). 

Schranth 2 has collected twenty-four examples of luxation of the 
cervical vertebrae, of which four are recorded as dislocations forwards, 
two back, and six to the one side or the other. Three of this number 
were dislocations of the atlas, two were disclocations of the second 
vertebra, five of the fourth, two of the fifth, two of the sixth, and one 
of the seventh. In the other cases the seat was not stated. 

Malgaigne has brought together forty -five examples ; of which 
twenty-one were complete forward luxations, nine incomplete forward 
luxations, nine unilateral and forwards, and four were backward lux- 
ations. Three were dislocations of the second vertebra upon the third, 
four were dislocations of the third vertebra, ten of the fourth, eleven 
of the fifth, fifteen of the sixth, and two of the seventh. 

The bilateral forward luxations are generally caused by a fall upon 
the top and back of the head, or upon the top of the head while the 
neck is very much flexed forwards. The unilateral is caused generally 
by a direct blow upon the back of the neck, the blow being probably 
directed somewhat to one side or the other. The number of backward 
luxations which have been reported are too few to enable us to indicate 
very accurately the general causes, but it seems probable that they are 
most often occasioned by a fall upon the fore and top part of the head, 
received while the neck is bent forcibly back. 

In dislocations of the cervical vertebrae forwards the head is usually 
depressed toward the sternum, in dislocations backwards the head is 
thrown back, and in unilateral dislocations the head is turned over 
one of the shoulders. Neither of these malpositions of the head is 
uniformly present in these several dislocations, and indeed not un- 

1 Charles Bell, on Injuries of the Spine, 1824. 

2 Schranth, Anier. Journ. Med. Sci., May, 1848, from Archiv. fiir Phys. Heil- 
kunde. 



546 DISLOCATIONS OF THE SPINE. 

frequently, especially in case the system is greatly shocked by the 
accident, the head and neck assume a preternatural mobility, and may 
be turned easily in any direction. 

The spinous process, unless the patient is very fleshy or consider- 
able swelling has supervened, can easily be felt, and its deviations to 
the right or to the left, forwards or backwards, furnish us with the 
most valuable and important sign of the dislocation. Even the trans- 
verse processes may be felt sometimes, especially in the upper part of 
the neck, with sufficient distinctness to render them useful in the 
diagnosis. 

To these circumstances we may add paralysis of the body below the 
seat of injury, with pain and swelling at the point of dislocation. In 
some cases also the patient has himself distinctly felt a cracking or 
sudden giving way in the neck at the moment of the accident. 

Prognosis. — The complete bilateral luxations, whether backwards or 
forwards, have in most cases terminated fatally within a short time, 
generally within forty-eight hours. Unilateral luxations are less speedy 
in their results, but when the dislocation remains unreduced, death 
generally takes place in a month or two. Lente relates a case of in- 
complete dislocation of the fifth cervical vertebra backwards, unaccom- 
panied with fracture, w 7 hich accident the patient survived five days. 1 
A patient of Roux's lived eight days ; but in the case of a second 
patient mentioned by Lente, with a complete luxation, without frac- 
ture, of the fifth vertebra, the patient survived the injury only two 
hours. 2 

On the other hand, occasional examples are presented of partial or 
complete recovery with the luxation unreduced. 

Horner, of Philadelphia, presented to the class of medical students 
of the University of Pennsylvania, in 1842, a lad, set. 10, w T ho had fallen 
a distance of twenty feet, alighting upon his head. He was found 
senseless and motionless, with his head bent under his body. He 
gradually recovered from the shock, but his neck was stiff, distorted, 
and motionless, his face being inclined downwards to the right side. 
Two days after, his " common and accurate perceptions returned, but 
he was affected for some time with tingling and numbness in his left 
arm." When presented to the class the transverse processes, from the 
fifth upwards, were about half an inch in front of those below, showing 
that the left oblique process of the fourth was dislocated forwards 
upon the fifth. The rotary motions of the neck could now be exe- 
cuted to some extent, but much more freely to the right than to the 
left. Professor Horner refused to make any attempt to reduce the 
dislocation. 3 

Dr. Purple, of New York, has reported a case of what was called a 
dislocation of the fifth and sixth cervical vertebrae, producing complete 
paralysis of the lower part of the body, in which the patient survived 
the accident many years ; but his lower extremities were so useless and 
cumbersome as to induce him, in the year 1851, six years after the 

1 Lente, New York Journ. Med., May, 1850, p. 284. 2 Lente, ibid., p 397. 

3 Horner, Amer. Journ. Med. Sci., April, 1843, from Med. Exam. 



OF THE SIX LOWER CERVICAL VERTEBRA. 547 

injury had been received, to submit to the amputation of both at the 
hip-joint. In 1852, having become very intemperate, he died, but no 
autopsy was obtained, so that the exact character of the injury was 
never ascertained. 1 Sanson, of Paris, has reported also a case which 
came under his observation at Hotel Dieu, of dislocation of the "third 
cervical vertebra backwards," from which, although unreduced, the 
patient partially recovered. The character of this accident was not 
much better determined ; for, although he felt a severe and sharp pain 
at the moment of the injury, which was greatly aggravated by motion, 
and his head was bent forwards and to the left, "the chin being fixed 
on the upper part of the sternum," there was no paralysis of either the 
motor or sentient nerves. After the lapse of about four months he left 
the hospital, still unable to lift his chin more than four inches from the 
sternum ; after which he resumed his usual occupations, suffering no 
further inconvenience than what was occasioned by the unnatural 
position of his head. 2 Notwithstanding the authoritative testimony 
of Sanson that this was a dislocation backwards, one cannot avoid the 
conclusion that it was either a unilateral subluxation, or perhaps a 
mere diastasis of the articulation, or else that it was an example of 
sprain of the muscles, and consequent contraction of one set, or paralysis 
of the opposing set of muscles. It is certain that it was not a complete, 
luxation ; nor, since there was no paralysis of the body below the point 
of injury, can it be properly made use of as an argument for non-inter- 
ference where such paralysis does actually exist. 

Let us see now what encouragement an attempt at reduction may 
offer, in a case which presents so little ground of hope where the re- 
duction is not accomplished. 

Dr. Spencer, of Ticonderoga, N. Y., relates that a man, set. 50, fell 
backwards from a board fence, striking upon the superior and ante- 
rior portion of his head, dislocating the second from the third vertebra 
of the neck. His head was thrown back so far as to prevent his seeing 
his own body, and all below the injury was completely paralyzed. 
Repeated attempts were made to reduce the dislocation, " but the trans- 
verse processes had become so interlocked that every effort proved 
abortive," and he died forty-eight hours after the injury was received. 3 
Gaitskill also attempted reduction in a case of dislocation of the seventh 
cervical vertebra, but failed. 4 Boyer failed in two cases. It is related 
by Petit Radel, that a young patient at La Charite expired in the 
hands of the surgeons, upon such an attempt being made a few days 
after the accident; 5 and Dupuytren says "the reduction of these dislo- 
cations is very dangerous, and we have often known an individual 
perish from the compression or elongation of the spinal marrow which 
always attends these attempts." 

Dr. Shuck, of Vienna, relates that a man, set. 24, while engaged at 
his work on December 5th, 1838, twisted his head suddenly round, in 

1 Purple, New York Journ, Med., May, 1853, p. 319. 

2 Sanson, Arner. Journ. Med. Sci., Feb 1836, p. 514; from Gaz. des Hopitaux. 

3 Spencer, Boston Med. and Surg. Journ., vol. xv, No. 11. 

4 Gaitskill, London Repository, vol. xv, p. 282. 

6 Petit Radel, Note to Boyer, 'Malad. Chir., vol. v, p. 118. 



548 DISLOCATIONS OF THE SPINE. 

consequence of one of his companions roaring into his ear, when he in- 
stantly felt something give way in his neck, and found it impossible to 
move his head. Next morning his head was turned to the right and 
bent down toward the shoulder. Every attempt to move his head 
caused great pain. He complained of weakness in his right arm, but 
all the other functions of his body were perfect. An attempt was im- 
mediately made to reduce the dislocation by lifting him by the head, 
but without success. On December 7th, the weakness and numbness 
of the right arm had increased, and the attempt to reduce the bones 
was renewed. The patient was laid horizontally upon a bed, and ex- 
tension made from the chin and occiput while counter-extension was 
made from the shoulders. The force thus employed was gradually in- 
creased until the patient and assistant felt a snap as of two bones meet- 
ing, when it was found that the head was restored to its natural posi- 
tion, and the power of moving it had returned. The next day his arm 
was more powerless than before, and on the following day he had ver- 
tigo, but these symptoms soon yielded to copious bleedings, and he left 
the hospital cured on the 13th. 1 

Dr. Hickerman, of Ohio, has reported also, in the Ohio Medical 
Journal, a case of dislocation of one of the cervical vertebrae, the origi- 
nal account of which I have not seen, but only an abridged statement 
published in the Buffalo Medical Journal. By exploring the pharynx 
a prominence was felt opposite the junction of the fourth and fifth cer- 
vical vertebra; and the action of the heart was barely perceptible. 
Seizing the patient's head under his left arm, Dr. Hickerman in this 
manner made traction, while with the index finger of the right hand 
in the patient's throat, he made firm pressure obliquely upwards, back- 
wards, and to the left; after continuing the pressure for about forty or 
fifty seconds, the part against which the finger was placed gradually 
yet quickly receded in the direction in which the pressure was made, 
and instantly, as quickly indeed as the act could be possibly executed, 
the patient opened her eyes, and natural respiration was established. 
She then also immediately became conscious of what was transpiring 
about her, and signified by signs, for she was yet unable to speak, that 
she had suffered pain in the epigastrium. Complete recovery took 
place. 2 

Schranth received under his care a patient who had a luxation of the 
" right transverse apophysis " of the fourth cervical vertebra, without 
lesion of the spinal marrow, which he reduced on the seventh day. 
The first attempt was unsuccessful ; but the second, made with great 
caution, by the aid of four assistants, three of whom pulled the head 
upwards while the fourth pressed with his whole weight upon the 
shoulders, was completely successful. During the time that the trac- 
tion was being made, the head was occasionally rotated slightly and 
moved laterally, and at the same moment the surgeon pushed firmly 
against the displaced apophysis. The reduction was attended with 
" various distinct crackings in the neck," which were loud enough to 

1 Shuck, Amer. Journ. Med. Sci., July, 1841, p. 207. 

2 Hickerman, Buf. Med. Journ., vol x, p. 702, April, 1855. 



OF THE SIX LOWER CERVICAL VERTEBRA. 549 

be heard. After some days of repose he resumed his occupation, no 
stiffness remaining in the movements of the neck. 1 

Dr. Edward Maxson, of Geneva, N. Y., was called, on the 28th of 
Oct. 1856, to see a child about nine years old, who had met with a 
similar accident about forty hours before, namely, a dislocation of the 
right articulating apophysis of the fifth or sixth cervical vertebra, occa- 
sioned by suddenly turning her head around while at play. She at 
first complained only of pain and inability to straighten the neck; but 
whenever moved she became faint and irritable. A short time before 
the surgeon was called, the mother had, in attempting to move her in 
bed, turned the face a little more to the left, when a severe convulsion 
immediately ensued. On examining the neck, Dr. Maxson discovered 
the displacement of the transverse process. Having advised the parents 
of the danger necessarily incident to an attempt at replacement, and of 
the probable consequences of its being permitted to remain as it was, 
they consented that the trial should be made. "I grasped the head," 
says Dr. Maxson, "with both hands, and proceeded according to De- 
sault's method, only I first carried or turned the face very gently a little 
further toward the left shoulder, to, if possible, disengage the process ; 
then lifting or extending the head, I turned the face very gently toward 
the right shoulder, when the difficulty was at once overcome, and she 
exclaimed: ' I can move my eyes.' Her countenance soon acquired a 
more natural appearance; the faintness passed off; she rested quietly 
through the night; had no return of the difficulty, and needed only an 
emollient anodyne to soothe the irritation and slight swelling which 
remained at the point of injury." 2 

Rust, 3 Wood, of this city, 4 and others, have seen and reported simi- 
lar cases attended with like success. 

So far the cases of successful reduction which we have described are 
examples of dislocation of only one of the articulating apophyses, 
and they are sufficiently numerous to establish the value of the prac- 
tice. We have now to relate a case in itself unique, namely, a suc- 
cessful reduction of a dislocation of the fifth cervical vertebra, in which 
both apophyses appear to have been thrown forwards. It occurred 
in the practice of Dr. Daniel Ayres, of Brooklyn, N. Y., and will be 
best understood by a reproduction of his own published account of the 
case: 

" E. K., the subject of this accident, was a laboring man, thirty 
years of age, tall and muscular, but not fat, with a neck longer than 
the average among men of equal height. On the evening of the 2d of 
October he became intoxicated ; was brought home insensible, and did 
not recover from the combined effects of the shock and his libations 
until the following morning, when he was supposed by his wife to be 
laboring under cold and a stiff neck. She made some domestic appli- 
cations to the affected part, and administered a dose of cathartic medi- 
cine. When it was thought sufficient time had elapsed without ob- 

1 Schranth, Amer. Journ Med. Sci., Mav, 1848. 

2 Maxson, Buffalo Med. Journ., Jan 1857, p. 476. 

3 Rust, Chelius, note by Smith. 

4 Wood, New York Journ. Med., Jan. 1857, p. 13. 



550 DISLOCATIONS OF THE SPINE. 



rards 



taining relief, he was seen by Dr. Potter, of this city, and afterward 
by Dr. Cullen, both of whom recognized a condition which was not 
only very unusual, but one which they had never before observed. I 
was then requested to examine the case, which I did on the ninth day 
after the accident. With some assistance and great personal effort, he 
was able to get out of bed, moving very slowly and cautiously. De- 
siring to expectorate, he was obliged to get down on his hands and 
knees, which he accomplished with the same deliberation. When 
seated in a chair, the head was thrown back and permanently fixed ; 
the face turned upwards with an anxious expression. The anterior 
portion of the neck, bulging forwards, was strongly convex, rendering 
the larynx very prominent. The integuments of this region were ex- 
ceedingly tense and intolerant of pressure. The posterior portion of 
the neck exhibited a sharp, sudden angle at the junction of the fifth 
and sixth cervical vertebrae, around which the integuments lay in 
folds. It was difficult to reach the bottom of this angle even with 
strong pressure of the fingers, and of course the regular line formed by 
the projecting spinous processes was abruptly lost. He complained of 
intense and constant pain at this point, which was neither relieved nor 
aggravated by pressure. With difficulty he swallowed small quan- 
tities of liquid, pausing after each effort, and could not be induced to 
take solid food, since the first attempt to do so after the accident was 
followed by violent paroxysms of coughing and choking. His breath- 
ing was obstructed and somewhat labored, being unable fully to clear 
the bronchia of their secretion. This, however, seemed rather an 
effect of the tense condition of the soft parts of the neck, than the 
result of pressure upon the spinal cord, since he presented no evidence 
of paralysis, either of motion or sensation, in parts below the neck. 
The sterno-cleido-mastoid muscles of both sides were felt quite soft and 
relaxed. 

" But one conclusion could be formed upon this state of facts, to 
wit : that the oblique processes of both sides were completely dislo- 
cated. The marked rigidity of the head seemed to preclude the proba- 
bility of fracture through the vertebral bodies, and although the carti- 
lage might be separated anteriorly, yet the body not pressing backwards 
sufficiently to produce paralysis of the cord, it was hoped that the pos- 
terior vertebral ligament remained uninjured; it was, therefore, deter- 
mined to make an effort at reduction on the following day. In addi- 
tion to those originally connected with the case, I am under obligations 
to Drs. Ingraham, Turner, Palmedo, G. D. Ayres, and a number of 
other medical gentlemen, who were present by invitation, all of whom 
confirmed the diagnosis, and rendered efficient services. 

" The patient was placed upon a strong table, in a recumbent posi- 
tion, with a pillow resting under the shoulders, the head being sup- 
ported by the hand during the administration of chloroform, of which 
an ounce was given before anaesthesia ensued. Counter-extension 
being made by two folded sheets placed obliquely across the shoulders 
and properly held, the head was grasped by one hand placed under 
the chin, the other over the occiput, and by steadily and firmly draw- 
ing the head directly backwards, and then upwards, an attempt was 



DISLOCATIONS OF THE ATLAS. 



551 



made at reduction, but failed for want of sufficient power. Dr. Ingra- 

harn was then requested to place his hands immediately over my own 

in the same position as before, and steady traction was again made in 

the same direction. Our united strength was required in drawing 

the head backwards and upwards to 

dislodge the superior oblique processes 

from their abnormal position. When 

this was felt to be yielding by Dr. 

Cullen (who kept one hand constantly 

at the seat of dislocation), Dr. Potter 

was directed to place his bands under 

our own, still in position, and assist in 

bringing the head forwards ; at the 

O O 7 

same time the chest was depressed 
toward the table. The bones were 
distinctly felt to slip into their places ; 
the line of the spine was instantly re- 
stored, the head and neck assuming 
their natural position and aspect. As 
soon as the patient became conscious, 
he expressed himself ignorant of what 
had taken place, but free from pain, 
and, in his own language, f all right.' 
A bandage was arranged to support 
the head and keep it bent forwards. 
He had an anodyne for two nights fol- 
lowing, after which no further treat- 
ment was necessary, and at the end of 
one week he had complete control over 
the movements of the head and neck. 

Beyond the debility and emaciation immediately dependent upon 
protracted fasting and loss of rest, he has experienced no uneasiness 
since the operation. His appetite is now good, and all the functions 
perform their duty normally. In a subsequent inquiry, to determine, 
if possible, the cause of the accident, he states that he distinctly 
recollects going into a store in Atlantic Street, near the ferry, and 
there having angry words with an acquaintance ; that he left the store, 
and was proceeding up the street (which is here a rather steep ascent), 
when he was violently struck from behind, over the lower portion 
of the neck. He likewise remembers falling forwards, and striking 
against some object, but does not know what it was, nor what took 
place until the following morning." 1 




Ayres's case of bilateral dislocation of the 
fifth cervical vertebra. 



\ 4. Dislocations of the Atlas. 

Surgeons have met with several forms of displacement between the 
atlas and axis. First, a forced inclination forwards of the atlas upon 
the axis ; in consequence of which the body or anterior arch of the 
atlas is made to recede from the odontoid process, and the transverse 



1 Ayres, New York Journ. Med., Jan. 1857, p. 



552 DISLOCATIONS OF THE SPINE. 

ligament glides upwards without breaking, so that the extremity of 
the odontoid process comes to occupy a position underneath or behind 
the ligament, and thus presses upon the cord. It is apparent also that 
this form of displacement cannot occur without a rupture of the ver- 
tical ligaments which bind the transverse ligaments to the axis, nor 
without a separation of the atlas from the axis posteriorly and a rup- 
ture of the posterior atlo-axoidean ligament. Second, a similar incli- 
nation of the atlas, accompanied with a rupture of the transverse and 
superior vertical ligaments, in consequence of which also the odontoid 
process is allowed to fall upon the cord. Third, the atlas in the same 
position, with the odontoid process broken at its base. Fourth, the 
atlas displaced directly forwards or backwards ; and fifth, a displace- 
ment of only one articular process in a direction forwards. 

We have already, when speaking of fractures of the atlas, or of the 
atlas and axis together, called attention to several examples of that 
form of the dislocation which is accompanied with a fracture of the 
odontoid process. The other forms of dislocation are characterized 
by so few symptoms peculiar to themselves, or which can be regarded 
as diagnostic and not already sufficiently studied in connection with 
other dislocations of the neck, that we shall not deem it necessary to 
do more than remind our readers, that if permitted to remain unre- 
duced a speedy and fatal issue is inevitable, and to point them to a 
couple of examples of recovery, after reduction has been fortunately 
accomplished ; for both of which I am indebted to Malgaigne. These 
may alone suffice to show that Dupuy tren was in error when he declared 
that such accidents were wholly beyond the resources of our art. 

An old man received upon his head a bundle of hay cast from the 
top of a wagon. He fell with his head bent forwards so that his chin 
touched the top of the sternum, and in this position it remained 
immovably fixed ; all the other portions of his body preserved their 
natural functions. A surgeon, who was indeed the father of Mal- 
gaigne, being called, assured the patient, that unless he could give him 
relief he certainly would die; but that inasmuch as the attempt might 
itself prove fatal, he ought at once to put in order his affairs. Accord- 
ingly the man partook of the sacrament; then the surgeon seated him 
upon the ground, and placing himself at his back with his knees 
resting upon his shoulders for the purpose of making counter-exten- 
sion, and with a towel brought over his own shoulders and under the 
chin of the patient for extension, he proceeded to act upon the neck in 
the direction of the axis of the spine. The efforts were long and pain- 
ful ; but at last, while the head was lifted as far as possible, it was 
suddenly drawn backwards, and immediately it resumed its natural 
direction. Absolute quietude was enjoined, and the patient recovered 
in a short time and without any accident. 

This patient was seen two years after by the younger Malgaigne, at 
which time no trace of the accident remained, except an impossibility 
of turning the head to the right or to the left. 

The other example is related by Ehrlich, but in this case the dislo- 
cation was backwards. A young man, set. 16, while carrying a sack 
of flour up a ladder, fell backwards, and the sack falling over upon his 



DISLOCATIONS OF THE RIBS FROM THE VERTEBRAE. 553 

face arid head came to the ground before him. He was found lying 
with his head thrown back and to the right, the head resting upon the 
scapula of this side, but having so completely lost its "solidity" that 
by its own weight it would fall from one side to the other. On the 
front and left side of the neck there existed a prominence supposed 
to be formed by the atlas ; the patient was unconscious ; the pulse was 
scarcely perceptible, and the whole body was suffering under paralysis. 
Ehrlich directed the shoulders to be held by one assistant, and the 
head to be drawn upon by another, while he pressed with his own 
hands forcibly upon the displaced atlas from behind. After several 
fruitless attempts, the reduction took place, accompanied with a sound 
distinctly audible to all of the assistants; the head resumed its posi- 
tion firmly, and the arms began to move. The head was afterwards 
maintained in place by a bandage. The cure proceeded rapidly, and 
after a time no trace of the injury remained but a disagreeable tension 
in the nape of the neck whenever he moved his head briskly to the 
one side or the other. 1 



\ 5. Dislocations of the Head upon the Atlas, or Occipito-Atloidean 

Dislocations. 

Lassus, Palletta, and Bouisson 2 have each reported one example of 
this dislocation. In neither case was the dislocation complete, but death 
occurred speedily in every instance. Dariste exhibited to the Anatomi- 
cal Society of Paris, in 1838, a specimen of incomplete luxation of the 
occipito-atloidean articulation, with stretching of the transverse liga- 
ment. The patient from whom the specimen was taken having lived 
more than a year after the accident, when he died from a tubercle in 
the brain. 3 



CHAPTEE IV. 

DISLOCATIONS OF THE KIBS. 

The ribs may be separated from the bodies of the vertebrae, from the 
cartilages of the ribs, and from each other. The cartilages of the ribs 
may also be separated from the sternum. 

I 1. Dislocations of the Ribs from the Vertebrae (Vertebro-costal). 

The heads of the ribs are joined to the bodies of the vertebrae by 
strong ligaments. The articulations are ginglymoid, admitting of mo- 
tion chiefly in the direction of the axis of the spine. The mobility 



1 Malgaigne, Ehrlich, Malgaigne, op. cit., torn, ii, p. 334. 

2 Lassus, Palletta, Bouisson, Malgaigne, op cit., p 320. 

3 Dariste, Amer. Journ. Med. Sci., Nov. 1838, p. 237, from Archives Gen., May, 
1838. 



554 DISLOCATIONS OF THE RIBS. 

gradually increases as we proceed from the first rib downwards to the 
last. Each joint is furnished with a capsule. 

The necks and tubercles are also united to the transverse processes 
by ligaments, and the articulations are furnished with synovial cap- 
sules. 

I am not aware that any examples have ever been reported of dislo- 
cations of the ribs from the transverse processes. 

Examples of dislocation of the heads of the ribs have been mentioned 
by Ambrose Par6, Bransby Cooper, Alcock, Donnie, Henkel, Kennedy, 
Buttet, and some others; but most of these reputed cases have not borne 
the test of a critical analysis, and while Vidal (de Cassis) is in doubt 
whether the claims of even one have been fully established, Boyer 
denies absolutely its possibility. We see no reason, however, to question 
the authenticity of several of these examples. 

The case mentioned by Bransby Cooper, although very briefly nar- 
rated, leaves no room for doubt as to its real character. " Mr. Web- 
ster, surgeon at St. Albans, when examining the body of a patient who 
had died of fever, found the head of the seventh rib thrown upon the 
front of the corresponding vertebra, and there anchylosed. Upon in- 
quiry, Mr. Webster learned that this gentleman, several years before, 
had been thrown from his horse across a gate, for which accident he 
had been subjected to the treatment usually followed in fractures of the 
ribs, and there is every reason to believe that it was at this time the 
dislocation occurred." 1 

These accidents seem to have been generally occasioned by a fall or 
a blow upon the back, and the dislocation has been accompanied, usu- 
ally, with a fracture of some other rib, or of the transverse or spinous 
processes of the corresponding vertebra?. The head of the rib has 
always been found to be displaced inwards. The lower ribs, includ- 
ing the false and floating, are those which have been most frequently 
displaced. 

It would be difficult, if not impossible, during the life of the patient, 
to make a positive diagnosis, since the symptoms resemble so closely 
those which accompany a fracture of the rib near its posterior extremity. 
The nature of the accident producing the dislocation, the depression, 
mobility, and pain, are equally indicative of a fracture; while the failure 
to detect crepitus might easily be explained by the thickness of the 
muscular walls at this point, or by the riding, or by other displace- 
ments of the broken fragments. 

Chelius speaks of a peculiar " rustling," perceived when the body 
and ribs are moved by the surgeon or by the patient himself, and 
which is different from the sensation produced by emphysema or frac- 
ture. 

The treatment ought to be the same which would be adopted in case 
the rib was broken. Replacement of the dislocated bone must be re- 
garded as impossible; and it only remains that we insure quiet as far 
as possible in this portion of the chest, and combat the pain and inflam- 
mation by suitable remedies. The circular bandage, however recom- 

1 Webster, B. Cooper's ed. of Sir Astley Cooper, Amer. ed., p. 450. 



DISLOCATIONS OF THE CARTILAGES OF THE RIBS. 555 

mended in these cases by Sir Astley Cooper, could only be serviceable 
in dislocations of those ribs which have an attachment to the sternum ; 
the floating ribs, which have been found dislocated quite as often as 
either of the others, could derive no support from circular pressure, or 
from any other mechanical contrivance. 

§ 2. Dislocations of the Cartilages of the Ribs from the Sternum 
(Sterno-Costal). 

The cartilage of the first rib has no proper articulation at either ex- 
tremity, but the remaining six upper ribs, where they join the sternum, 
are furnished with synovial capsules. In old age these articulations 
generally disappear, yet not always. 

Charles Bell observes : " A young man playing the dumb-bells and 
throwing his arms behind him, feels something give way on the chest ; 
and one of the cartilages of the ribs has started and stands prominent. 
To reduce it, we make the patient draw a full inspiration, and with the 
fingers knead the projecting cartilage into its place. We apply a com- 
press and bandage, but the luxation is with difficulty retained." 

Ravaton, Manzotti, and Monteggia have each, according to Mal- 
gaigne, reported one example of traumatic dislocation ; in all of which 
the cartilages were thrown forwards in advance of the sternum. 

When treating of fracture of the sternum, I have related one case, 
which has come under my own observation, of dislocation of three or 
four cartilages at the same time. 

Dr. Samuel D. Flagg, of St. Paul, Minn., relates as follows : 

"During the evening of June 29th, 1871, a girl, set. 10, while 
playing with several children, ran violently against the corner of an 
ordinary deal table. It is stated that the child was faint and breathed 
with difficulty for a short time, but soon returned to play. No swell- 
ing or other evidence of injury was observed by her friends. 

"On the 1st July, about forty-eight hours after receiving the injury, 
while exercising somewhat violently, she complained of sudden pain at 
the left costo-sternal. articulation and a sensation of something having 
given w T av. Soon afterwards I saw the child for the first time, and 
found a slight non-crepitant swelling at the latter point, and the ster- 
nal extremity of the cartilage of the fourth rib displaced forward, its 
posterior surface being very nearly on a plane with the anterior surface 
of the sternum. A minute fragment of bone, unconnected with the 
sternum or cartilage, was noticed, which I took to be a fragment chipped 
off from the margin of the articular depression on the edge of the ster- 
num. Neither pain nor embarrassed respiration were notably promi- 
nent; crepitus could be detected, but not very distinctly; preternatural 
mobility was very evident." 1 

By pressure alone restoration has generally been effected, the cartilage 
resuming its position suddenly and with a sound. The reduction may, 
nevertheless, be facilitated by bending the trunk backwards, or by 
directing the patient to make a full inspiration. 

1 Flagg, Northwestern Med. and Surg. Jour., Aug. 1871. 



556 DISLOCATIONS OF THE RIBS. 



.. 



To maintain the reduction has been found more difficult, and Sir 
Astley directs that " a long piece of wetted pasteboard should be placed 
in the course of three of the ribs and their cartilages, the injured rib 
being in the centre ; this dries upon the chest, takes the exact form of 
the parts, prevents motion, and affords the same support as a splint 
upon a fractured limb. A flannel roller is to be applied over this 
splint, and a system of depletion pursued, to prevent inflammation of 
the thoracic viscera." Instead of the pasteboard, we might use either 
felt, sole-leather, or gutta-percha. 

The patients spoken of by Ravaton and Manzotti were both cured 
in about one month. 

Mr. Bransby Cooper says that a baker's boy applied for relief at 
Guy's Hospital, who was the subject of displacement of the cartilages 
of the fifth and sixth ribs from their junction with the sternum, pro- 
duced partly by the constant action of the pectoral muscles in kneading 
bread, but principally by his defective constitution. Mr. Cooper stated 
to the boy the necessity of changing his occupation, and advised him 
to go into the country ; but as he was unable to do so, little hope was 
entertained of his recovery. 1 



\ 3. Dislocation of one Cartilage upon Another. 

The cartilages on the sixth, seventh, and eighth ribs are furnished 
at their lower borders with a true arthrodial joint, by which they artic- 
ulate with the corresponding cartilages. This arrangement sometimes 
extends to the fifth and ninth ribs. 

A displacement of these articulations may take place when one falls 
upon his back, striking upon some projecting body, so that the chest is 
suddenly thrown forwards ; in consequence of which the upper margin 
of the lower cartilage is depressed and entangled behind the lower 
margin of the upper. The inferior cartilage is, therefore, the one which 
is displaced rather than the superior, although this latter being made 
prominent by the pressure of the other from behind, seems alone to be 
displaced. Boyer, Martin, and Malgaigne have each reported one ex- 
ample. 

It is probable that the contraction of the pectoral and abdominal 
muscles has a chief agency in the production of these dislocations, and 
that they are not solely or directly due to the shock of the accident. 

The treatment consists in pressing firmly upwards and backwards 
against the inferior margin of the upper, or overlapping rib, so as to 
disengage it from the lower, when by its own elasticity it will resume 
its natural position. The reduction might also be aided by a full in- 
spiration. 

1 B. Cooper's ed. of Sir Astley Cooper, etc., op. cit., p. 447. 



DISLOCATIONS OF THE CLAVICLE. 557 



CHAPTER V. 

DISLOCATIONS OF THE CLAVICLE. 

Of 50 dislocations of the clavicle observed by me, 9 belonged to the 
sternal end and 41 to the acromial. Of those belonging to the sternal 
end, 7 were dislocations forwards, forwards and upwards, or forwards 
and downwards, and 2 were upwards. I have never met with a dis- 
location backwards. Of the acromial dislocations the whole number 
were dislocations upwards, or upwards and outwards. 

\ 1. Sterno-Clavicular. 
(a.) Dislocation Forwards at the Sternal End. 

Causes. — This accident is generally caused by a fall upon the point 
of the shoulder, in consequence of which the sternal end of the clav- 
icle is driven forcibly inwards and forwards. It is probable, also, 
that the blow which produces the dislocation is received rather upon 
the anterior and outer face than exactly upon the extremity of the 
shoulder. A sudden effort of the muscles, as in the attempt to balance 
a weight upon the head, or to throw the shoulders backwards when 
under drill, has been known also to produce this dislocation. In one 
example it was occasioned by placing the knee against the spine and 
drawing the shoulders forcibly back. Various other accidents, the 
philosophy of whose agency is not so easily explained, are said to have 
produced the same result; but it is not improbable that in many of 
these cases the precise manner in which the injury was received has 
not been correctly understood or reported. 

Mr. Fergusson has once seen this displacement in a newly-born in- 
fant, which had happened during birth. It could be replaced with 
ease, but immediately slipped out again when left to itself. " Nothing 
was done ; a new joint formed, and the child afterwards possessed as 
much power in the one arm as in the other." 1 

Symptoms. — The head of the bone, unless the person is exceedingly 
fat, or great swelling has supervened, can be distinctly felt and seen in 
front of the sternum; the corresponding shoulder falls a little back; 
the head inclines also sometimes to the same side ; the movements of 
the arm are embarrassed, and accompanied almost alw r ays with an acute 
pain at the point of dislocation. The clavicular portion of the sterno- 
cleido-mastoid muscle presents an unusually sharp and projecting out- 

1 Fergusson, System of Practical Surgery, Amer. ed., 1853, p. 203. 



558 



DISLOCATIONS OF THE CLAVICLE. 



Fig. 252. 




Dislocation of the sternal end forwards. 



line, and a careful measurement indicates, if the dislocation is complete, 

a sensible approach to the acromion 
process toward the centre of the ster- 
num. If now the surgeon places his 
knee against the spine, and draws the 
shoulders back, the projection of the 
clavicle in front diminishes or disap- 
pears ; if he carries the shoulder up, 
it descends; and if he depresses the 
shoulder, it ascends. 

The simplicity and uniformity of 
the symptoms which usually charac- 
terize this accident will generally 
prevent the possibility of a mistake ; 
but Pinel mentions the case of a man 
who, having presented himself at one 
of the hospitals of Paris, suffering un- 
der this dislocation, the surgeon-in-chief thought it a tumor of the 
bone, and advised the application of a plaster; and, on the other hand, 
a patient presented himself to Velpeau, who had been treated for a dis- 
location, when the bone was only expanded by disease. 

I have myself also seen a fracture so near the sternal end of the bone 
as not to be easily distinguished from a dislocation. 

Pathology. — In complete anterior luxation of the clavicle, the cap- 
sular ligament suffers a complete disruption, and also the anterior with 
the posterior sterno-clavicular ligaments. The rhomboid and interar- 
ticular ligaments suffer more or less, according to the extent of the dis- 
placement. The interarticular cartilage may retain its attachment to 
the sternum, or it may be carried forwards with the clavicle. The 
head of the bone lies immediately underneath the skin and in front 
of the sternum; and generally it is found to have descended a little 
upon its anterior surface. Bicherand saw a case in which the sternal 
extremity of the bone was placed three inches below the top of the 
sternum. 

Wherever the bone lies it carries with it the clavicular fasciculus of 
the sterno-cleido-mastoid muscle. 

Treatment — Not one of the seven forward dislocations of the clavi- 
cle at the sternal end seen by me has been completely reduced, or if 
reduced they have not been retained in place. In the following ex- 
ample the reduction, although faithfully attempted, was never accom- 
plished. 

Mr. H., of Buffalo, set. 45, was thrown by a horse, suffering at the 
same moment a fracture of the leg and a forward dislocation of the left 
clavicle at its sternal end. 

Prof. James P. White, with whom I was in consultation, made sev- 
eral attempts to reduce the dislocation by placing the knee against the 
spine and pulling the shoulder forcibly back, and the same efforts were 
repeated by myself, but without accomplishing the reduction. We also 
endeavored to reduce it by pressing directly upon the projecting bone 



DISLOCATION FORWARDS AT THE STERNAL END. 559 

and by placing a pad in the axilla, using the arm as a lever, as recom- 
mended by Desault, and with no better result. 

This patient was tolerably muscular, but while we were manipulat- 
ing he was very much enfeebled by the shock of the accident. 

Finding that it was impossible to reduce the dislocation by any mod- 
erate amount of force, and believing that if we were to succeed we could 
not retain the bone in place, and the more especially because his left 
side was so much bruised that he could not bear an axillary pad or 
bandages of any kind, we desisted from any further attempts. 

Two years later I examined the shoulder and found the clavicle still 
unreduced, and its position unchanged. When he carries the shoulder 
forwards or backwards, there is a corresponding motion at the sternal 
end of the clavicle. The arm is not quite as strong as the other, and 
its freedom of motion is slightly impaired. 

I have also in my museum the cast of a case of complete forward 
dislocation at this point; which accident occurred in a lad twelve years 
old, who had fallen into a cellar on the 20th of Aug. 1856. The late 
Dr. Lewis and Dr. Dayton, both excellent surgeons, had examined the 
arm, and dressings had been applied with a view to maintain the re- 
duction ; but on the fifth day after the accident I found the bone dis- 
placed ; nor do I think reduction was ever afterwards maintained. 

A lad was brought into the Buffalo Hospital of the Sisters of Charity, 
with a dislocation of the same character, on the 25th of Sept. 1858, 
who had been run over by a w T agon on the same day. Dr. E. P. 
Smith, one of the surgeons of the hospital, attempted faithfully to re- 
duce it, but was unable to do so. Five days after, I found the bone 
out and quite movable. All apparatus having been removed, we laid 
him upon his back in bed, and kept him in this position three weeks. 
He was then dismissed with no change in the appearance of the bone, 
but he could move the arm as well as before the accident. 

Other surgeons have not met with, or at least they have not men- 
tioned, any cases in whiclvthe reduction of this dislocation was attended 
with difficulty, nor am I prepared to explain the difficulty which was 
experienced in my own (Mr. H.), and in Dr. E. P. Smith's case. 
Probably they ought to be regarded as exceptions to the general rule. 
But most surgeons have testified to the difficulty of retaining it in place 
when reduction has been fairly accomplished. Chelius says, " there 
commonly remains more or less deformity," and Malgaigne says that 
"it is difficult and rare to cure it without deformity." 

Nevertheless, Desault (or, rather, his pupil Bichat, who has published 
his lectures), who always speaks very confidently of his ability to re- 
tain either broken or dislocated bones in their places, says that he 
"almost always obtained complete success" with his apparatus. It 
is remarkable, however, that of the three examples furnished by Bichat 
to confirm this statement, all of which were treated by Desault himself, 
one recovered after a long time with a " very perceptible protuberance 
in front of the sternum," one with a " very slight protuberance," and 
in the other the " swelling was almost gone" on the twentieth day, and 
we are left in doubt as to whether the reduction was any more complete 



560 



DISLOCATIONS OF THE CLAVICLE. 







than in either of the other cases. 1 Richerand and Guersant succeeded 
no better with Desault's dressings. 2 

Other surgeons have made similar claims for their own forms of ap- 
paratus, but experience still continues to show that a complete reten- 
tion of the dislocated bone is seldom to be expected. 

Sir Astley Cooper recommends an apparatus, the construction and 
application of which are illustrated by the accompanying sketch, the ob- 
ject of which is to draw the shoul- 
ders back, and at the same time, 
by the aid of two pads or cushions 
in the axilla?, to carry the shoul- 
ders outwards. The dressing is 
then completed by placing the 
arm in a sling. He advises, 
however, that in some way di- 
rect pressure should be made 
upon the projecting point of 
bone. 

Velpeau objects to any plan 
which will draw the shoulders 
back ; but, on the contrary, he 
thinks that the shoulders should 
be kept slightly forwards, so as 
to diminish the tendency of the 
sternal end of the clavicle to 
escape in this direction. 

Until further observations 
have determined the relative 
value of these and of many 
other processes, it will be well 
to adopt no fixed rule of action; 
but, having reduced the bone by either placing the knee upon the spine 
and drawing the shoulders back, or by making use of the humerus as 
a lever, we recommend that the surgeon shall seek to maintain it in 
place by such means as the experiment shall prove are most successful. 
Among these means, direct pressure upon the sternal end of the clavicle, 
the sling, and perfect quietude of the muscles of the arm through the 
aid of bandages, are no doubt of the greatest importance, and can seldom 
be omitted. If then we find that a position of the shoulders more or 
less forwards or backwards best maintains the apposition, this position, 
whatever it is, ought to be continued. 

In order to be successful, sufficient time must elapse for the torn 
ligaments to become firmly reunited, during which the reduction must 
be constant ; since every time the bone escapes, the whole work of 
repair has to be recommenced as from the beginning. To this end at 
least four or six weeks are necessary, and sometimes the period must 
be lengthened far beyond these limits ; so that it may often become a 



Sir Astley Cooper's apparatus for dislocated clavicle. 



1 Desault on Fractures and Dislocations, by Xav. Biehat, Philada. ed., 1805, p. 52. 

2 Alalgaigne, op. cit. , torn, ii, p. 417. 



OF THE STERNAL END OF CLAVICLE UPWARDS. 561 

grave point of inquiry whether the long confinement of the limb will 
not entail more serious consequences than have ever been known to 
arise from leaving the bone displaced. In no case seen by me has the 
function of the arm been seriously impaired by the displacement. 

(b.) Dislocation of the Sternal End of the Clavicle 

Upwards. 

Malgaigne has collected four undoubted examples of this dislocation, 
and I have been unable to find a report of any other except the very 
extraordinary case described by Dr. Rochester, at the September meet- 
ing of the Buffalo Medical Association, and which case, through the 
courtesy of Dr. Rochester, I was permitted to see several times. 1 

Jerry McAuliffe, set. 44, on the 28th of August, 1858, while seated 
upon a load of wood, was caught under the bar of a gateway and 
violently crushed, the right shoulder being forced downwards and a 
little backwards. Dr. Rochester saw him very soon after the accident. 
On examination, it was found that the sternal extremity of the right 
clavicle was thrown upwards so far as to rest upon the front of the 
thyroid cartilage, occasioning considerable pain, difficulty of respira- 
tion, and loss of speech. Reduction was easily effected, and a retentive 
apparatus was immediately applied, consisting of a gutta-percha splint, 
moulded to the clavicle and ribs, and retained in place with adhesive 
plaster. Suitable bandages, a sling, etc., were also employed to main- 
tain complete rest. 

Notwithstanding all the care employed, the bone again became dis- 
placed, and when, near four months after the accident, this man came 
before the class of medical students at the Hospital of the Sisters of 
Charity, we found the sternal end of the clavicle carried upwards half 
an inch, and across toward the opposite side also about half an inch, 
and projecting somewhat in front. It was fixed in this position by 
ligaments which allowed it to move much more freely than natural, 
but which would not permit any great displacement. The correspond- 
ing shoulder was slightly depressed. McAuliffe said that he felt no 
inconvenience or abatement of strength in the arm except when he 
attempted to lift weights above his head. 

In April, 1870, I met with a similar case in a woman fifty years of 
age, which had been caused by a fall upon the shoulders nine weeks 
before, and which had been overlooked by her surgeon in the first in- 
stance. When seen by me it was immovably fixed in its new position. 

The accident seems to have been produced, in all the cases, so far 
as can be ascertained, by a force operating upon the end and top of 
the shoulder; in consequence of which the head of the clavicle is 
pushed and at the same time lifted, as it were, from its socket, tearing 
not only its capsule with the ligaments which immediately invewt the 
capsule, but also in some instances the costo-clavicular ligament w 7 ith 
some fibres of the subclavian muscle. The sternal end of the clavicle 
is found riding upon the top of the sternum, its head being placed 
between the sternal fasciculus of the sterno-cleido-mastoid muscle on 



562 DISLOCATIONS OF THE CLAVICLE. 

the one hand, and the sternohyoid muscle on the other. In one of th< 
cases seen by Malgaigne the head had traversed in this direction com- 
pletely the intra-clavicular space, and lay behind the sternal portion oi 
the opposite sterno-cleido-mastoid muscle. 

The symptoms are, a depression of the shoulder, with an elevation 
of the sternal end of the clavicle so as to increase sensibly the space 
between it and the first rib. The clavicle also encroaches more or 
less upon the supra-sternal fossa, occasioning a corresponding dimin- 
ution of the space between the end of the shoulder and the centre of 
the sternum. The sternal portion of one or both of the sterno-cleido- 
mastoid muscles may also be seen raised and rendered tense by the 
pressure of the head of the bone from behind. 

Fig. 254. 



Dislocation of the sternal end of the clavicle upwards. 

Reduction has been found easy, but Malgaigne thinks a perfect 
retention impossible, at least it does not seem to have been accom- 
plished in any of the cases reported. In no case did the displacement 
seriously impair the functions of the arm. 

The same apparatus to which we shall give the preference in cases 
of dislocation upwards of the acromial end of the clavicle, at least with 
only such slight modifications as the peculiarities of the case will nat- 
urally suggest, will be suitable for this accident. The shoulder must 
be lifted by a sling, while the sternal end of the clavicle is pressed 
downwards by a pad and bandages ; and all the muscles of the arm 
and chest, so far as is consistent with respiration and comfort, must be 
maintained in a state of perfect rest until the ligaments have become 
reunited. 

(c.) Dislocations of the Sternal end of the Clavicle 

Backwards. 

The first case upon record of this kind of accident, caused by vio- 
lence, was published by Pellieux, in 1834, in the Revue Medicate; 
until which time its existence had been generally denied. In the 
London and Edinburgh Journal of Medical Science for October, 1841, 
several cases are mentioned. 



OF THE STERNAL END OF CLAVICLE UPWARDS. 563 

Two forms of the accident have been described, one in which the 
head of the clavicle is driven backwards and a little downwards; and 
another in which it is displaced directly backwards, or backwards and 
a little upwards. In both of these classes, the end of the bone falls 
inwards toward the opposite clavicle, and occupies a space in the 
cellular tissue back of the sterno-hyoid and sterno-thyroid muscles, 
and in front of the oesophagus ; the trachea, if reached at all, being 
probably thrust to the opposite side. 

The examples in which it has been found below the top of the 
sternum are much the most numerous ; indeed, it is probable that the 
other form is only a secondary displacement, occasioned by the action 
of the fibres of 'the sterno-cleido-mastoid muscle. 

Causes. — Of the eleven examples mentioned by Malgaigne, four 
were occasioned by direct blows, and most of the remainder by crush- 
ing accidents, as by powerful lateral compression of the shoulders. 

One of the cases produced by a direct blow was accompanied with 
an external wound, and is the only instance of a compound dislocation 
of this kind upon record. The man was admitted into St. Thomas's 
Hospital in Sept. 1835, and, according to his own account, the sharp 
end of a pickaxe had been driven through the flesh against the bone. 
The sternal end of the clavicle was found to be displaced backwards, 
and with the finger thrust into the wound on the front of the chest, it 
could be distinctly felt resting upon the side and front of the trachea, 
wdiere it interfered somewhat with respiration and deglutition. He 
had a great desire to cough, with a sensation of pressure on his wind- 
pipe, which was greatly increased wdien his head was thrown back. 
There was also a slight emphysema in the region below the collar-bone 
and over the top of the sternum. The shoulder having been brought 
back with straps attached to a back-board, the bone readily resumed 
its place. The elbow was then brought forwards and bound to the 
side, and the wound being closed with adhesive plaster, he was put to 
bed with the shoulders much raised. No unfavorable symptoms fol- 
lowed, and in three weeks he left his bed. Three weeks later he left 
the hospital with the sternal end of the bone still falling a little back- 
wards, and rather more movable than natural. 1 

The following example, related by Morel-Lavallee, will illustrate 
that class in which the dislocation results from an indirect blow, or 
from a crushing accident. 

Lemoine, seventeen years old, had his right shoulder violently pressed 
against a wall by a carriage. He experienced at the moment some pain 
at the bottom of his neck, and a great sensation of suffocation, which 
lasted for more than a quarter of an hour. The dyspnoea gradually 
subsided, but the motion of the right arm not returning, he, on the 
eighth day after the accident, entered La Charite. On examination, 
the two shoulders were found to be on the same level, but the right one 
was nearer the median line. The internal extremity of the clavicle was 
half concealed behind the sternum. On depressing the shoulder, the 
inner end of the clavicle arose and disengaged itself from behind the 

1 South, note to Chelius's Surgery, Amer. ed., vol. ii, p. 218. 



564 DISLOCATIONS OF THE CLAVICLE. 

sternum; but reduction was effected by elevating the shoulder, while at 
the same time it was carried outwards and backwards. Desault's 
bandage was then applied, but as it became loosened, Velpeau's was 
substituted, which kept the bone completely in position until the 
eighteenth day, when the patient was lost sight of. 1 

Symptoms. — The most constant symptoms are, the absence of the 
head of the bone from its socket, and its complete or partial disappear- 
ance behind the sternum, an approach of the corresponding shoulder to 
the median line, an inclination of the head to the opposite side, eleva- 
tion of the shoulder, pain at the bottom of the neck, impairment of the 
motions of the arm, sometimes difficulty in respiration and in degluti- 
tion, partial arrest in the circulation of the arm from pressure upon the 
subclavian artery, and a slight projection of the acromial end of the 
clavicle, noticed twice by Morel-Lavallee. 

It has not generally been found difficult to reduce this dislocation, 
nor, when reduced, is it so liable to again become displaced as are the 
dislocations forwards; yet in only a few instances has the restoration 
been so complete as not to leave some deformity. 

In order to the reduction, the shoulder must be carried generally up- 
wards, outwards, and backwards, and it may then be best maintained 
in position by laying the patient on his back upon an elevated cushion, 
as practiced by Tyrrell in the case related by South. To this may be 
added such other measures, differing but little from those employed in 
other dislocations of the clavicle, as are necessary to insure complete 
rest to the muscles. Of course, no pads or bands across the clavicle 
can be of any service in this case. 

As in the other cases of dislocation at this point, the patients have 
generally recovered nearly the full use of their arms, even in one or 
two instances in which the reduction has never been accomplished. 

? 2. Acromioclavicular. 

(a.) Dislocation of the Acromial End of the Clavicle 

Upwards. 

Of all the dislocations of the clavicle, this form is most frequent. I 
have met with it either as a partial or complete luxation forty-one times. 
The youngest subject was seven years of age, and the oldest sixty-three. 
All but two were males. 

Causes. — It is produced generally by a fall upon the extremity of the 
shoulder. Twice the blow has been received rather upon the back than 
upon the extremity, and once it was occasioned by the fall of a board 
directly upon the top of the shoulder, and once by a bolt thrust directly 
up from under the clavicle. 

Symptoms. — When the dislocation is complete, the clavicle not only 
is lifted from its articular facet to the extent of the breadth of the bone, 
but it is pushed more or less outwards over the top of the acromion 
process; generally less than half an inch, but I have once seen it riding 

1 Morel-Lavallee, Amer. Journ. Med. Sci , vol. xxix, p. 229, 1842; from Gaz. 
M6d. 



OF THE ACROMIAL END OF CLAVICLE UPWARDS. 565 

the process to the extent of three-quarters of an inch. In this last ex- 
ample, the case of James Moran, a strong, healthy laboring man, the 
clavicle was easily reduced, and it always went into place with a sensi- 
ble click; but although every possible care was taken to retain it in 
place by bandages, compresses, an axillary pad, and a sling, yet it was 
not accomplished, and on the third day he removed all the dressings, 
and refused to have them reapplied. 

I have usually found the shoulder slightly depressed ; and in one in- 
stance, where it is probable the deltoid muscle had suffered some injury, 
the elbow hung away from the body, and any attempts to lay it against 
the side produced an acute pain in the shoulder. 1 It has been noticed 
also, in most cases, that the clavicular portion of the trapezius muscle 
appeared lifted and tense, especially when the neck was straight. 

Inability to raise the arm to a right angle with the body is a general 
but not constant symptom. In two instances, where the displacement 
was only moderate, the patients were at first and for some time after- 
wards unable to lift the arm in any degree from the side. In one ex- 
ample, a lady sixty years of age had fallen upon her shoulder and pro- 
duced a dislocation upwards, but she had not consulted a surgeon until 
she called upon me, five months after the accident. The clavicle was 
then raised from its socket about half an inch, but it could be easily 
pressed back to its place, the reduction being attended with a grating 
sensation, a circumstance which I have not noticed in any other instance. 
She was not even then able to raise her arm to her head, nor had she 
been able to do so since the accident occurred. 

In all the motions of the arm and shoulder, the clavicle is seen to 
move more freely than natural immediately under the skin, and these 
motions are usually attended with some pain at the point of dislocation. 

This accident has been sometimes mistaken for a dislocation of the 
humerus, but unless the shoulder is already greatly swollen, the error 
is not likely to happen. If the point of the acromion process can be 
made out, it will be easy to determine, by sliding the finger along its 
spine, whether the clavicle is displaced or not, and by these means to 
settle the question of its complicity in the accident. The question as 
to whether the shoulder is dislocated or not may be more difficult of 
solution, as we shall hereafter have occasion again to observe. 

Pathology. — Generally there exists simply a rupture of the ligaments 
immediately investing the joint, so that the clavicle rises from its socket 
only about half an inch, more or less, according to its diameter, and is 
carried outwards just sufficiently far to allow it to rest upon the upper 
margin of the acromial articulation. In at least twenty-nine of the 
cases seen by me this has been the position of the acromial end of the 
clavicle, and for its complete reduction nothing more has been required 
than to press with moderate force upon the upper and outer end of the 
bone. 

In eight cases I have found the bone not only thus lifted in its 
socket, but also driven over upon the acromion process from half to 

1 Report on Dislocations, by the author. Transac. of New York State Med. Soc., 
1855, p. 19. 



566 



DISLOCATIONS OF THE CLAVICLE. 



three-quarters of an inch ; and in one instance, that of a gentleman, 
Mr. B., who was injured in a railroad accident, the acromial end of the 
clavicle was displaced outwards half an inch and backwards three- 
quarters of an inch, while the sternal end also was considerably lifted 
in its socket and slightly sent inwards. The shoulder fell forwards 
and the coracoid process was one inch nearer the sternum than the 
same process upon the opposite side. In such cases more or less of the 
fibres of the coraco-clavicular ligament must have suffered a disrup- 
tion; indeed, without a rupture of its external fasciculus, which anato- 
mists have called the trapezoid ligament, such a dislocation cannot take 
place. 

Prognosis. — It is impossible for me to say what has been the precise 
result in all the cases which I have seen, but my notes furnish only 
two cases of perfect retention after a complete dislocation at this point. 



Fig. 255. 



Fig. 256. 





Dislocation of the acromial end of the clavicle 
upwards. 



Dislocation of the acromial end of the 
clavicle upwards and outwards. 



One of these, David Thomas, aged about twenty-five years, fell side- 
ways upon the ground, striking upon the extremity, and, as he thinks, 
a little upon the top of the shoulder. I found the clavicle dislocated 
upwards and outwards, so that it overlapped the acromion process half 
an inch. It was easily replaced, and having applied my own appa- 
ratus for broken collar-bones, with the addition of a band across the 
shoulder and under the elbow to keep the clavicle down, I found that 
I had succeeded in retaining the bone in place. This dressing was 
continued until the forty-second day, when, on being removed, the 
clavicle was seen to be closely confined upon its articulation ; and after 
a lapse of two years it still retains its position so completely that no 
difference can be detected between the opposite articulations. 

In the case of Moran, already mentioned, whose clavicle overlapped 
the acromion process three-quarters of an inch, and who threw off the 
dressings at the end of three days, the same degree of displacement ex- 



OF THE ACROMIAL END OF CLAVICLE UPWARDS. 567 

isted at the end of two years ; the scapular end of the clavicle moving 
freely in every direction under the skin according as the arm was moved. 
In lifting, he says, the strength of his arm is undiminished until he 
raises the weight nearly to a level with his shoulders, and from this 
point upwards he can lift but little. For a laboring man it amounts to 
a serious maiming. I have seen the same loss of power in the arm to 
raise bodies above the head in at least two or three of the examples of 
less complete luxation, continuing after the lapse of several years ; but 
in the majority of cases, although the bone does not remain reduced, 
the patients have recovered eventually the complete use of the arm in 
whatever position it may be placed. 

The case to which I have already referred as having been caused by 
a bolt thrust upwards under the clavicle, will furnish the best illustra- 
tion of this general principle. James O'Brien, 1st U. S. Artillery, 
was injured in September, 1862, by being run over by a horse-car. 
A bolt, three-quarters of an inch in diameter, w T as driven through the 
skin on the anterior margin of the left axilla, breaking the first rib, 
severing the coraco-clavicular ligaments, and forcing the clavicle up- 
wards from its socket. No attempt at reduction was ever made. When 
seen by me one year after the accident, the outer end of the clavicle 
was lifted directly up two inches from the acromion process, to which 
it was united only by a long and slender ligament. He was not con- 
scious of any loss of power or limitation of motion in the injured arm. 
At my request, my son, then in the U. S. service, instituted a series of 
experiments to test the relative strength of the two arms, and with the 
following result: First with the right arm, and then with the left, he 
lifted from the ground fifty-six pounds and three ounces, and sustained 
this weight above his head thirty seconds, with his arms fully extended. 
With his right arm extended at full length, at right angles with his 
body, he sustained twenty-five pounds for fifteen seconds. With the 
left arm he sustained the same weight, in the same position, seventeen 
seconds. 1 

Treatment. — When the bone simply rises upon its socket, the reduc- 
tion is always easily accomplished by pressing firmly upon its extremity 
with the fingers ; but if, at the same time, it has been carried outwards, 
or outwards and backwards, the reduction is only accomplished by 
pulling the shoulders backwards, or by placing a pad in the axilla, 
using the arm as a lever, or by lifting the arm by the elbow and at the 
same time pressing the clavicle down ; and it will sometimes require 
the application of all or several of these procedures at the same moment. 
In some cases the complete reduction has only been effected when the 
patient has been brought under the influence of an anaesthetic. 

As to the maintenance of the bone in its socket for a length of time 
sufficient to insure a firm union of the broken tissues, this will be found 
always more difficult, and, in a great majority of cases, absolutely im- 
possible. Nearly all surgeons who have written upon this subject have 
made the same observation; and if occasionally a new apparatus in the 
hands of a clever surgeon' has seemed to promise better results, the 

i Am. Med. Times, Oct. 24, 1863. 



568 



DISLOCATIONS OF THE CLAVICLE. 



same apparatus in the hands of other equally clever surgeons, and 
under circumstances equally favorable, has been found almost con- 



- 



i- 



stantly to fail; and we have been compelled again to exercise anew our 
ingenuity, and to seek for new resources, or to abandon the effort in 
despair. 

Dr. Folts, of Boston, believed that he had found in Bartlett's appa 
ratus for broken clavicles, modified by the application of a shoulder- 
strap, the infallible remedy for this one of the many sad defects in our 
art. The most important part of this dressing, according to Dr. Folts, 
is the compress placed upon the upper and outer end of the clavicle, 
and the bandage or strap passed over the compress and under the point 
of the elbow to maintain it in position. 1 

Dr. Folts is no doubt correct in regarding this strap as an important 
if not the essential part of the apparatus; and it is surprising that by 
Sir Astley Cooper, as well as by many other experienced surgeons, its 
value should have been overlooked. The chief obstacle to the reten- 
tion of the bone in place is the powerful action of the trapezius, whic. 
constantly tends to elevate the outer end of the bone. In some measur* 
this may be resisted by elevating very forcibly the shoulder, or by in 
dining the head, but both of these positions are extremely fatiguing, 
and will not be long endured. The bandage or strap, adjusted in the 
manner which Dr. Folts has recommended, is the only means of coun- 
teracting the action of the trapezius, upon which any substantial reli- 
ance can be placed; but the principle has long been understood and 
practiced upon. Bradsor's tourniquet, or Petit's, secured by a strap 
brought under the point of the elbow, Boyer's double shoulder-straps, 
and Desault's third bandage, all aimed at the accomplishment of the 
same purpose; yet Boyer and Desault found all these contrivances fail 
in a majority of cases. Mayor employed a dressing constructed with a 
strap to buckle over the dislocated clavicle, but Nelaton has seen this 
apparatus fail also, when applied in his own wards. 

The experience of Dr. Folts at the time of his report did not extend 
beyond three cases, and the apparatus had been completely successful 
in only two of the three. Our own experience is sufficient to show that 
it will be found occasionally, but by no means constantly, successful. 
We have already mentioned two cases in which we succeeded perfectly 
by this mode, but in several others which seemed equally favorable we 
have met with partial or complete failures. 

The practical difficulties are, the sensibility and consequent inability 
sometimes of the point of the elbow to bear the requisite pressure, and 
the even greater sensibility of the skin over the top of the clavicle; the 
tendency of the bandage to slide off from the shoulder and also to be- 
come displaced from the end of the elbow ; the gradual relaxation of 
the bandages, which, when existing even in the most inconsiderable 
degree, is sufficient sometimes to allow the bone to slip out from its 
shallow socket; the impossibility of fixing the scapula, upon whose im- 
mobility as well as upon the immobility of the clavicle the retention 



1 Folts, Bost. Med. and Surg. Journ., vol. liii, p. 259. 



OF THE ACROMIAL END OF CLAVICLE UPWARDS. 569 



Fig. 257. 




Mayor's apparatus for dislocated clavicle. ("Tri- 
angle cubito-bis-scapulaire.") 



depends ; and, finally, the great length of time requisite to unite firmly 
the ligaments, if indeed they ever again become actually united. 

The band can be prevented in 
some measure from sliding off 
from the clavicle by a counter- 
band attached to a collar upon 
the opposite shoulder, but not 
without causing some pain and 
giving rise to excoriations gener- 
ally in the opposite axilla; and, 
in a degree, all the other diffi- 
culties may be met by patience 
and ingenuity, but unfortunately 
the smallest failure in any one 
of these numerous indications 
insures a defeat. 

The axillary pad employed as 
a fulcrum upon which extension 
may be made is equally as dan- 
gerous here as in fractures, and I 
do not think it ought ever to be 
used for this purpose, but only 
as a means of moderate support 
and retention ; indeed it would 
be well, perhaps, if it were dis- 
carded altogether. 

The case of Mr. B., already quoted, with a dislocation outwards and 
backwards, affords not only an illustration of the inefficiency of either 
the shoulder-strap or the axillary pad in certain cases, but also, it 
seems to me, of the mischief which may result from their too diligent 
application ; for I cannot persuade myself but that most of the maim- 
ing in this case was due to the apparatus rather than to the original 
accident. 

This gentleman was injured on the 10th of November, 1855. A 
sling with an axillary pad and bandages was immediately applied. I 
saw him on the seventeenth day. The displacement was then such as 
I have described, but I did not observe any paralysis or emaciation of 
the limb. Having noticed that the clavicle fell into its socket when 
he lay upon his back in bed, at my suggestion all the dressings except 
the sling, were removed, and the patient was laid upon his back in 
bed, with instructions to continue in this position, if possible, until the 
cure was completed; but after a few days I received a communication 
from his physician, stating that, owing to a troublesome cough, he had 
found it impossible to maintain this position. His residence was forty 
or fifty miles from town, and I sent him one of my dressings for broken 
collar-bones with instructions as to its use; directing especially that a 
shoulder-strap should be used to keep the clavicle down. 

The dressing was applied and continued six weeks, and on being 
removed, the elbow, wrist, and finger-joints were found to be stiff. 
The whole arm was emaciated and almost powerless. One year later 

37 



570 



DISLOCATIONS OF THE CLAVICLE. 



there was no improvement in the condition of the arm; every joinl 
from the shoulder down was almost completely anchylosed, the iriuscles 
were greatly wasted, and the hand trembled constantly. 

These results, it seems to me, were due to too long and too tight band- 
aging of the arm, and especially to the pressure of the axillary pad. I 
do not state this positively, but this is my belief. 

Is it worth while, then, to incur the dangers of too long confinement 
and of excessive bandaging for the purpose of attaining the always un- 
certain result of maintaining the bone in its socket? We certainly 
may be permitted to make the attempt within certain reasonable limits; 
and especially if the patient is a female and the avoidance of deformity 
is a point of serious consideration ; but never without keeping constantly 
in mind the possibility of a permanent anchylosis and paralysis of the 
limb. 



(b.) Dislocation of the Acromial End of the Clavicle 

Downwards. 

This form of dislocation is exceedingly rare, only three well-authen- 
ticated cases having been placed upon record, one of which was seen 
and dissected by Melle in 1765, the second was met with by Fleury 
in 1816, and the third is described by Tournel. 

Cause. — So far as we can ascertain, it has been produced only by a 
force which has acted directly upon the top of the clavicle. In the 
case mentioned by Tournel, a horse had trod upon the shoulder ; and 
in the example recorded by Melle, the accident occurred in a child six 
years old, from an attempt to support a great weight upon the top of 
the collar-bone. In this last example the humerus was dislocated also, 
and both dislocations had remained unreduced many years when the 
patient was seen by Melle. 

This force acting directly upon the top of the clavicle would fail to 
dislocate the bone, except by first breaking down the coracoid process, 
if it did not happen sometimes that at the same moment the lower angle 
of the scapula was thrown outwards, in such a manner as to depress 
slightly the coracoid process, and thus to permit the outer end of the 
clavicle to fall below the level of the acromion process. 

Symptoms and Pathology. — This dislocation, whether it has been 
produced artificially upon the dead subject or accidentally upon the 
living, has always been found to be accompanied with a complete 
rupture of the acromioclavicular ligaments not only, but also of the 
coraco-acromial and coraco-clavicular ligaments; the outer extremity 
of the bone resting between the acromion process and the capsule of the 
shoulder-joint, and a little posterior to the articulating facet which 
originally received the clavicle. 

The superior angle of the scapula approaches the body slightly, and 
its inferior angle is thrown outwards. A marked depression exists at 
the point of dislocation, accompanied with a sharp pain, increased 
especially when an attempt is made to move the arm. The patient is 
unable to lift the arm voluntarily, but it can be moved pretty freely 



END OF THE CLAVICLE UNDER CORACOID PROCESS. 571 

in the direction forwards and backwards by the hands of the surgeon : 
abduction is much more difficult. 

Treatment. — Reduction is easily accomplished. At least, in the only 
two examples upon the living subject in which the attempt has been 
made, it was effected promptly by drawing the shoulders gently out- 
wards and backwards ; nor has it been found any more difficult to 
maintain it in position when once replaced. When the scapula is re- 
stored to its natural position, and its lower angle approaches again the 
side of the body, a reluxation becomes impossible; since the coracoid 
process now effectually prevents that descent of the clavicle upon which 
its displacement always depends. It is only necessary, therefore, to 
secure the scapula at its base and lower angle snugly to the body, by a 
broad band and compress, and all the indications of treatment are com- 
pletely fulfilled. 

(c.) Dislocation of the Acromial End of the Clavicle 

UNDER THE CORACOID PROCESS. 

Pinjou met with one example of this singular dislocation, 1 and 
Godemer, or Mayenne, has recorded five more, 2 and these constitute the 
whole number which are at this day known to science. 

Cause. — Age and a consequent relaxation of the ligaments seem to 
constitute a predisposing cause, since of the six recorded examples four 
were between the ages of sixty-seven and seventy-one, and the other 
two were adults. In all the cases, also, the dislocation was the result 
of a fall upon the shoulder. 

The symptoms which have been said to characterize this accident are 
pain and a very marked depression at the point of displacement, with 
a corresponding projection of the acromion and coracoid processes; a 
rapid inclination outwards and downwards of the line of the cjavicle, 
its outer extremity being felt in the axilla; the corresponding shoulder 
depressed and inclined forwards; freedom of motion in all directions 
except inwards and upwards ; the lower angle of the scapula thrown 
outwards and backwards ; to which Morel-Lavallee has added an actual 
increase of space between the acromion process and the sternum. 

Treatment. — Godemer reduced all the examples which came under 
his notice easily, by directing an assistant to pull the arm backwards 
and outwards while he himself seized upon the clavicle with his fingers, 
and disengaged it from under the process; but Pinjou, after many 
efforts by the same method, failed completely, and the patient having 
left him, the clavicle was reduced the next day by an empiric. Yidal 
(de Cassis) recommends that instead of pulling the arm outwards, by 
which procedure the pectoralis major is made to antagonize the surgeon, 
the elbow shall be brought down to the side, and kept there by the 
left hand, while the right hand, placed in the axilla, shall pull the 
upper end of the humerus outwards, converting the arm into a lever of 

1 Pinjou, Journ. de Med. de Lyon, Juillet, 1842, from Vidal (de Cassis). 

2 Godemer, Recueil dc* travaux de la Soc. Med. d'Indre et Loire, 1843, from 
Vidal. 



572 



DISLOCATIONS OF THE CLAVICLE. 



t 

most 



the third kind. This process, I confess, seems to be much the mos 
rational. 

Finally, having given the history of these cases as they have been 
reported, we shall scarcely have performed our duty as a faithful writer 
if we do not state frankly that we entertain a suspicion that both the 
gentlemen who have reported these curious examples have entertained 
us with fabulous or imaginary stories; and especially do these suspi- 
cions rest upon the cases reported by Godemer, who in five years saw 
five cases, each presenting throughout the same class of symptoms, the 
same facility of reduction, accomplished by the same means, and alwavs 
with the same perfect result. 

' If to these singular coincidences we add the fact that only one other 
surgeon has ever claimed to have met with the accident, and if we 
notice the actual anatomical difficulties which stand in the way of its 
occurrence, such especially as the complete occlusion of the subcora- 
coidean space by the tendons and muscles which pass from its extrem- 
ity toward the chest and arm, we shall find a fair apology for some 
degree of skepticism. 



(d.) Dislocation of the Clavicle at both Ends, 

SIMULTANEOUSLY. 






On the 26th of January, 1863, Dr. North, of Brooklyn, N. Y., was 
called to see a lad fourteen years of age, who had been thrown with 
violence backwards from a stool upon which he was sitting, striking 
the back of his left shoulder against the floor. Dr. North found him 
suffering severely from pain, and with some difficulty of breathing. 
The shoulder was depressed and thrown forwards. The sternal end of 
the clavicle, turned forwards, formed an abrupt, rounded prominence; 
the acromial end, turned forwards also, presented its longest diameter 
toward the surface, and rested above the acromion process ; while the 
central portion seemed depressed or thrown back, an appearance whie 
was caused by the rotation of the clavicle upon its axis. 

Reduction was accomplished by throwing the shoulders forcibly 
backwards, and at the same time pressing with the thumbs upon the 
two extremities in such a manner as to reverse the rotation, as follows: 
pressing at the acromial end backwards and downwards, and at the 
sternal end backwards and upwards. The restoration was complete, 
and the bones were retained in place by compresses and adhesive plas- 
ters, with the aid of Day's " neck yoke." At the end of three weeks 
the dressings were removed ; and when last seen by his surgeon "there 
was but little, if any, trace of the accident remaining." It is the 
opinion of Dr. North that the rotation was caused by the action of the 
pectoralis major and deltoid after the dislocation took place. 1 

Erichsen says that Richerand and Morel-Laval lee have each reported 
one example of double dislocation of the clavicle. 

Dr. Stanley Haynes, of Malvern Link, has reported the only re- 
maining case of which I have been able to find a record. 

1 N. L. North, M.D., New York Med. Kecord, April 16th, 1866 



DISLOCATIONS OF THE SHOULDER. 573 

" A girl, aged 13, rapidly growing, of lax tissues, and of a consump- 
tive family, but who had always had good health, while washing the 
back of her neck with her left hand, one morning in September, felt 
something give way in the shoulder of the same side. I found dislo- 
cation forwards of the sternal end of the clavicle and partial luxation 
upwards of the acromial one. There was very little pain. Both ex- 
tremities of the bone were easily replaced by drawing the shoulder 
backwards and downwards, but the double deformity was reproduced 
immediately the shoulder was liberated. A pad was applied under a 
figure-of-8 bandage over the sternal end, and the arm was placed in a 
sling as a temporary measure. To a strap, fastening round the chest, 
a strap bearing a truss-pad was attached in such a manner that the pad 
kept the sternal end of the clavicle reduced, the other end of the strap 
passing over the shoulder and diagonally across the back to the hori- 
zontal strap: the wearing of a sling kept the acromial end in its natural 
position. The patient soon afterwards returned to school at a distance. 
She is now at home, and I have found the sling has been discontinued 
some time, that the straps have stretched and are useless, and that the 
ends of the bone are as mobile as, but not more than, they w<ere when 
I first saw the patient, but that the sternal end does not become luxated 
unless the arm is raised, when it nearly always starts forwards." 1 



CHAPTEE VI. 

DISLOCATIONS OF THE SHOULDEK (SCAPULO-HUMEKAL). 

Owing to the great exposure and the peculiar anatomical structure 
of the shoulder-joint, its structure having reference mainly to freedom 
of motion rather than to firmness and security in the articulation, dis- 
locations of the humerus are very common. 

Writers have not been agreed as to the precise anatomical relations 
of these dislocations, nor as to the nomenclature. Velpeau, Malgaigne, 
Vidal (de Cassis), Skey, and Sir Astley Cooper have each adopted ex- 
planations and classifications peculiar to themselves. With the arrange- 
ment established by this latter surgeon, English and American students 
are the most familiar; and believing that it is more simple, and quite 
as appropriate as either of the others, I shall adopt it as the basis of 
my own descriptions. 

I shall have occasion, however, to dissent from the opinions and 
teachings of this distinguished surgeon, as to the exact seat and rela- 
tions of the head of the humerus in some of these dislocations. 

According to Sir Astley Cooper, there are three complete luxations 
of the shoulder ; namely, downwards, forwards, and backwards. 

1 The British Medical Journal, Jan. 27th, 1872. 



574 DISLOCATIONS OF THE SHOULDER. 



I 1. Dislocation of the Shoulder Downwards (Subglenoid). 

This is usually called a dislocation into the axilla ; the head of the 
bone resting rather upon the inner side of the inferior border of the 
scapula, near the base of that triangular surface which is found below 
the glenoid fossa. 

Since in both the other complete dislocations of the shoulder, the 
head of the humerus, in order to escape from its socket, must be made 
to descend more or less downwards, we shall regard this dislocation as 
the type of all the others, and shall make it the subject of especial 
consideration as well as of reference when speaking of the other forms 
of dislocation. 

Causes. — The most frequent cause of this accident is a blow received 
directly upon the upper end and outer surface of the humerus. I have 
found the arm disjocated into the axilla by this cause twenty-one times; 
five times by a fall upon the extended hand ; three times by a fall upon 
the elbow ; and in these latter cases the arm was probably carried away 
from the body at the moment of the receipt of the injury. 

In all the above examples the shoulder has been dislocated by the 
simple force of the blow, or with only slight aid from muscular action; 
but in a considerable number of cases the bone is displaced almost 
wholly by the action of the muscles, the arm having been previously 
violently abducted; and perhaps in some cases the capsule being torn 
before the resistance of the overstrained muscles has accomplished the 
displacement. Thus, in three instances I have known the dislocation 
to result from holding on to the reins after being thrown from a car- 
riage; in two cases the patients have fallen through a hatchway and 
been caught and suspended by the arms ; once a woman met with this 
accident by holding on to a pump-handle when she had slipped and 
fallen upon the ice. A few years since I examined the arm of a Swiss 
woman, Maria Norregan, who was then sixty-five years old, and whose 
humerus had been dislocated into the axilla seventeen years before, 
where it still remained. Her own account of the accident was, that 
she was returning from the Jura Mountains, near Neufchatel, with a 
load of hay upon her head. She had carried it a long way with her 
hands held upwards, without once stopping to rest, and when at length 
she threw down the load at her door, the right shoulder was dislocated. 
The arm soon became very painful, and swollen to the fingers' ends; 
but she was too remote from, and too poor to employ, a surgeon. A 
tailor, who used to do the minor surgery of the neighborhood, bled her 
three or four times, but the dislocation was not recognized until many 
months after. 

A Mrs. Hunn informed me that when she was twenty-two years old 
she had a convulsion, and that her attendants in trying to hold her 
upon her bed, actually pulled the shoulder out of joint. After the first 
accident the dislocation was not repeated for four years, but since then 
it had occurred from very slight causes many times. She was in the 
habit of reducing it herself by placing a ball in the axilla and using 
the arm as a lever. 



DISLOCATION OF THE SHOULDER DOWNWARDS. 0/0 



Dr. Lehman reports the case of a sailor on board an American brig, 
who was subject to a dislocation into the axilla from very slight causes, 
and especially if he bent his body far over to raise anything. He 
could also, by pulling horizontally, remove the head of the bone from 
its socket. It was reduced easily, and he experienced no pain either in 
the reduction or dislocation, nor, indeed, during the displacement. 1 

Pathology. — In this accident the head of the bone is made to press 
against the capsule below and immediately in front of the long head of 
the triceps, until the capsule gives way, and continuing to descend in 
the same direction it is finally arrested by the triangular surface of the 
inferior edge of the scapula immediately below the glenoid fossa. 
Owing to the pressure, of the tendon of the triceps behind, it occupies 
a position also a little in advance of the centre of this triangle, or rather 
upon its anterior edge, so that it rests more or less upon the belly of the 
subscapularis muscle. 

The capsule is generally torn quite extensively, especially below and 
in front; and the tendon of the long head of the biceps may be broken 
asunder, or detached completely 



Fig. 258. 



from its insertion ; the supra- 
spinatns muscle is stretched or 
lacerated; the infra-spinatus, 
subscapularis, and coraco-bra- 
chialis are put upon the stretch ; 
the subscapularis being also 
sometimes completely torn from 
its attachment to the head of 
the humerus, and in either case, 
whether torn or merely com- 
pressed and stretched, the cir- 
cumflex nerve, which runs 
along its lower margin, is sub- 
ject to severe injury ; the deltoid 
muscle is also placed .in a con- 
dition of extreme tension; while 
the teres major and minor in 
this respect are subjected to but 
little change. 

In some cases a portion or 
the whole of the greater tuber- 
osity is completely detached, and the fragment displaced by the action 
of the muscles inserted into it. 

In one case the axillary artery has been ruptured. The patient had 
been thrown down by a runaway horse, and was taken to Jervis Street 
Hospital, London. On the tenth day Surgeon O'Reilly tied the sub- 
clavian artery, and the patient recovered after the loss of two fingers 
from erysipelas and gangrene. 2 

With more or less rapidity, after the occurrence of the dislocation, if 




Dislocation of the shoulder downwards into the 
axilla. (Subglenoid.) 



1 Lehman, Amer Journ. Med. Sci., vol i, p. 242, 18'_'8. 

2 Todd's Cyclop. Anat. and Surg., p 616 ; Holmes's Surg. vol. ii. p. 827. 



576 



DISLOCATIONS OF THE SHOULDER. 



the bone remains unreduced, various changes take place in the ana- 
tomical relations and structure of the parts. The following is a brief 
account of the condition in which the parts were found in the case of 
an old man, whose history is unknown. The dissection was made by 
my assistant Dr. Frank Deems, at the Bellevue dead house. The 
head of the humerus was in front of the socket, below the coracoid pro- 
cess, lying upon the anterior surface of the neck of the scapula. A 
new socket was formed in the bone at this point, mostly cartilaginous, 
and a fibrous capsule inclosed the head of the humerus. The margins 
of the old socket were removed, and the socket was filled with fibrous 
tissue. The axillary nerves and artery were not injured or compressed. 
The biceps tendon was not torn. All the muscles about the shoulder 
were atrophied. 

Symptoms. — A palpable depression immediately under the extremity 
of the acromion process, more distinct in children, in very old and in 
thin people, than in adults of middle life or than in fat or muscular 
people, but never absent completely, unless the shoulder is very much 
swollen ; the elbow carried out from the body three or four inches, 



Fig. 259. 




Dislocation of the shoulder downwards into the axilla. (Subglenoid.) 



sometimes a little backwards, and the line of its axis directed toward 
the axilla ; the outer surface of the arm presenting two planes inclined 
toward each other, and meeting at the point of insertion of the deltoid 
muscle; the head of the humerus felt in the axilla, particularly when 
the elbow is carried away from the body; numbness of the arm, accom- 
panied generally with pain, especially when any attempt is made to 
press the elbow against the side ; rigidity with inability to move the 



DISLOCATION OF THE SHOULDER DOWNWARDS. 577 

arm freely in any direction, but especially inwards; allowing, however, 
of pretty free passive motion, bat not permitting the elbow to touch 
the body without great pain, which pain is occasioned mostly by the 
pressure of the humerus upon the axillary plexus; under no circum- 
stance can the hand be placed upon the opposite shoulder while at the 
same moment the elbow touches the thorax ; the head of the patient, 
and sometimes the whole body, inclined toward the injured arm ; the 
arm lengthened from half an inch to an inch ; a chafing or friction 
sound is not unfrequently present, especially if the bone has been some 
days dislocated ; but Mr. Lawrence mentions a case in which there was 
a distinct crepitus, yet there was no fracture ; Dr. Hays saw a similar 
case in Wills Hospital, Philadelphia, in a woman sixty years old, whose 
arm had been dislocated forwards eight weeks. 1 Other surgeons have 
related like examples, but it is probable that in all these cases there 
has been an exposure of the bone at or near the edge of the glenoid 
fossa, by the partial detachment of its ligamentous margin, or some 
portion of the head has become divested of its cartilaginous covering. 
(For a more complete differential diagnosis, see chapter on fractures of 
the humerus.) 

Decisive as these signs usually are of the true nature of the accident, 
cases will every now and then occur in which the diagnosis will be 
attended with great difficulty, and especially if a few hours have been 
permitted to elapse since the occurrence of the injury, so that consider- 
able effusions of blood and of lymph may have taken place ; while at a 
still later period, when the swelling has subsided, the diagnosis again 
becomes easy. " At this latter period," says Sir Astley Cooper, " it is 
that surgeons of the metropolis are usually consulted ; and if we detect 
a dislocation which has been overlooked, it is our duty in candor to 
state to the patient that the difficulty of detecting the nature of the 
accident is exceedingly diminished by the cessation of inflammation, 
and the absence of tumefaction." 

It has never happened to me to have seen a case of dislocation into 
the axilla which I have not easily recognized, but in my report to the 
New York State Medical Society, already referred to, I have related 
two cases which were not recognized by the patients themselves, and 
no surgeon was called until after several days or weeks, and three cases 
in which empirics having been employed they failed to detect the dis- 
location ; and since the date of the report, I have met with many simi- 
lar examples which had not been recognized by intelligent surgeons. 
Although, therefore, I am prepared to admit the justness of the obser- 
vations made by Sir Astley Cooper, I think that if the case is seen 
within an hour or two after the accident, its nature may be generally 
determined promptly by the surgeon of experience; but upon this sub- 
ject I have already spoken very fully in the chapter on fractures of the 
humerus ; and from the examples and opinions which I have there pre- 
sented it will be inferred that it is much more common to mistake a 
fracture for a dislocation, than a dislocation for a fracture, an observa- 

1 Lawrence, Hays, Amer. Journ. Med. Sci., vol. xxiv, p. 236, May, 1839. 



578 DISLOCATIONS OF THE SHOULDER. 

tion which is equally as applicable to dislocations forwards as to the 
form of dislocation now under consideration. 

Prognosis. — If the force which displaced the bone was not great, or 
if the shoulder-joint has not suffered any injury from the accident itself 
beyond the mere rupture of the capsule and a moderate straining of 
the muscles, and if the dislocation has been early and easily reduced, 
the patient is immediately after the reduction able to move the arm 
freely in all directions ; very little swelling follows, and in a short time 
a perfect restoration of all the functions of the limb is accomplished. 

It cannot, however, always be inferred from the degree of violence 
employed in the production of the dislocation, nor from the absence or 
presence of swelling, how much injury the tendons, muscles, and nerves 
have suffered, since the same causes produce greater lesions in one per- 
son than in another, and the amount of swelling may depend upon the 
accidental rupture of an unimportant bloodvessel, or upon some pecu- 
liarity in the constitution of the patient predisposing to serous, fibrous, 
or sanguineous effusions. 

To whatever cause we may find occasion to attribute the result, it 
will nevertheless be observed, that, in a great majority of cases, the 
limb is not restored to all its original strength and freedom of motion 
until after the lapse of some months ; and the shoulder does not resume 
its perfect form and symmetry until a much later period ; occasional 
pains, especially after exercise of the muscles, and in certain conditions 
of the weather, are present also at irregular intervals and for indefinite 
periods of time. Opposite and more favorable terminations must be 
regarded as exceptions to the rule. 

Where the reduction has been made within a few hours, I have 
found the shoulder affected with muscular anchylosis with more or 
less weakness of the arm after a lapse of from a few days to one or two 
years. 

A laborer, set. 41, had dislocated his right shoulder into the axilla. 
Dr. H., an intelligent young surgeon, reduced the bone easily with his 
hands alone, while the patient was still unconscious from the shock of 
the injury. After six weeks he called upon me, accompanied by his 
surgeon, thinking that it was not properly reduced because the arm 
was still painful, and he could not move it freely. The bone was, 
however, well in its socket. One year later I examined this man, and 
found some anchylosis remaining in the shoulder-joint. 

James Rogers, set. 39, fell while running, and struck upon his right 
shoulder. Dr. Eastman, Professor of Anatomy in the Buffalo Medical 
College, reduced the dislocation four hours after the occurrence, in 
the following manner : The patient being seated in a chair, Dr. East- 
man placed his knee in the axilla and manipulated, while one assistant 
supported the acromion process, and another pulled downwards upon 
the forearm. The time occupied in the reduction was about two 
minutes, and the bone finally resumed its position with a snap audible 
to all the persons in the room. For some months after, and at the 
period when I was invited to see him, the muscles about the shoulder 
were rigid, and the motions of the joint embarrassed ; but at the end 



DISLOCATION OF THE SHOULDEE DOWNWARDS. 579 

of two years, Dr. Eastman informed me that the joint had become free 
and the arm as useful as before, except that he could not throw a stone. 

In another case, a gentleman residing in an adjoining county, set. 
42, was thrown from his carriage, falling forwards upon his hands. 
The dislocation was reduced promptly, by placing the heel in the 
axilla, and within fifteen minutes after it had occurred. Three months 
after this the patient consulted me on account of the immobility of 
the shoulder-joint, and because several surgeons had expressed a 
doubt whether it was properly reduced. The anchylosis was then so 
complete that the humerus could not be moved separately from the 
scapula, but there w T as no displacement. This gentleman again called 
upon me at the end of four years, and I then found the arm nearly 
restored to its original condition, but it was not quite so strong as 
before. He experienced also "curious" sensations in his arm and 
hand occasionally. The anchylosis had continued with very little 
improvement about two years, after which it had been gradually dis- 
appearing. 

I need scarcely say that in those examples in which the reduction 
of the bone has been delayed beyond a few hours, or for several days 
or weeks, the continuance of the anchylosis has been more persistent ; 
but in no case which has come under my observation, unless the bone 
still remained unreduced, has the anchylosis been permanent. For 
this reason I am disposed to think that muscular, rather than fibrous 
or ligamentous anchylosis, is the cause, generally, of the immobility 
of the joint. I have certainly never in any instance met with a true 
bony anchylosis as a consequence of a shoulder dislocation. The an- 
chylosis in question seems to be a result simply of laceration or more 
generally of a severe strain of the muscular fibres, resulting in in- 
flammation and a contraction of these fibres ; and its occurrence in 
any particular case may therefore be justly attributable either to the 
position of the bone when it is dislocated, to the force of the blow 
which has produced the dislocation, or to the violence applied in the 
attempts at reduction. 

Paralysis and wasting of the muscles of the arm, either w r ith or 
without muscular contraction and rigidity, are also observed in a cer- 
tain number of cases. Especially has it been noticed that the deltoid 
muscle is liable to atrophy; and in their attempts to explain the fre- 
quency of its occurrence in this latter muscle, surgeons have generally 
referred to a probable rupture of the circumflex nerve, a circumstance 
which the autopsies show does occasionally take place; or to a mere 
stretching of this nerve; yet it is quite as fair to presume that in 
many cases it is due solely to the greater injury which the deltoid 
muscle has sustained by the unnatural position of the head of the 
bone during the continuance of the dislocation, for, with the exception 
of the supra-spinatus, it is placed more upon the stretch than any other. 
Nor is it improbable that in some cases it is due to the mere force of 
the blow which, having been received directly upon the top of the 
shoulder, has contused the muscle. In short, any of the causes which 
may determine in the deltoid inflammation and consequent rigidity, 
must finally result in desuetude and consequent atrophy. 



580 DISLOCATIONS OF THE SHOULDER. 

In quite a number of cases my attention has been called to a remark- 
able fulness just in front of the head of the bone, which has continued 
sometimes for many months and even years after the reduction has 
been effected, the patients having in several cases applied to me to 
know whether this did not indicate that the bone was not in its socket, 
especially as it has been usually attended with some stiffness in the 
joint. Not unfrequently I have been told that surgeons who had 
noticed this fulness, thought the bone was not reduced ; and in one in- 
stance I am informed that a jury returned a verdict against the surgeon, 
where there was no other evidence of malpractice than this fulness with 
some anchylosis, but which, in the opinion of these gentlemen, was 
conclusive evidence that the bone was not properly set. The deception 
is also often the more complete from the fact that there may exist a 
corresponding depression underneath the acromion process, behind. 

It may be present where but little force has been used, either in the 
production of the dislocation, or in its reduction. I have seen it in a 
girl, only fourteen years of age, who had dislocated her left shoulder 
into the axilla, by a fall upon a slippery sidewalk. I reduced the 
bone, assisted by Dr. George Burwell, within half an hour after the 
accident. Dr. Burwell held upon the acromion process w r hile I lifted 
the arm to a right angle with the body, and pulled gently, and the 
reduction was at once accomplished; but we immediately noticed that 
the head of the bone seemed to press forwards in the socket so as to 
resemble what Sir Astley Cooper has described as a partial forward 
luxation. There was also a corresponding depression behind. Carry- 
ing the elbow back rendered the projection more decided, but bringing 
it forwards would not make it entirely disappear. 

In other instances much more difficulty has been experienced, and 
more force has been employed in the reduction. A man weighing 
two hundred pounds, and forty-one years of age, residing at Bath, in 
Steuben Co., fell from a load of hay in May, 1853, striking upon the 
top and front of the left shoulder. It was immediately ascertained 
that he had dislocated his arm into the axilla, and broken his leg. A 
young surgeon attempted within a few minutes to reduce the disloca- 
tion, but failed; and about two hours later it was reduced by another 
surgeon, with the aid of chloroform and Jarvis's adjuster. Four years 
after the accident had occurred, this gentleman came to me accom- 
panied by the surgeon who had made the reduction, in consequence 
of its having been intimated by some medical men that it was not 
properly reduced. The arm was not as strong as the other; some 
anchylosis existed at the shoulder-joint ; but especially it was noticed 
that there still remained a remarkable fulness in front, as if the head 
of the bone was pressed forwards. By no manipulation or position 
could this fulness be made to disappear, yet the bone was plainly 
enough in its socket. 

This phenomenon is probably due in some cases to a rupture of the 
supraspinatus muscle, and the consequent preponderating action of the 
antagonizing muscles, or to the laceration of the capsule, but most 
often, I imagine, to a rupture or to a displacement of the long head of 



DISLOCATION OF THE SHOULDER DOWNWARDS. 581 

the biceps, a circumstance to which I shall more particularly allude 
under the subject of " partial dislocations." 

Among the results of this dislocation must be placed a tendency to 
reluxation, which, although it may not often be made manifest by its 
actual occurrence, owing perhaps to the prudence of the surgeon, yet 
it does take place in a sufficient number of cases to establish its peculiar 
liability. Indeed, we need only consider how imperfect is the protec- 
tion against this accident, when once the capsule has been torn, to ap- 
preciate this observation. Examples of spontaneous luxation, or of 
luxation of the shoulder from very trivial causes, after it has once been 
luxated, may be found in the experience of almost every surgeon. I 
have myself met with several persons who have had repeated luxations 
from a slight cause, and in some instances, where the patients were 
subject to epilepsy, the luxations have occurred whenever the convul- 
sions returned. 

A gentleman residing at Toronto, Canada West, had a dislocation 
of the right shoulder into the axilla when he was quite a child, and 
the accident was renewed when twenty-nine years old by falling from 
a carriage head foremost, with his right arm extended and uplifted. 
Since then, until he called upon me, a period of about six years, he 
has been constantly subject to the same dislocation ; and he cannot 
raise his arm high above his shoulders without producing a subluxa- 
tion, the head of the humerus resting upon the outer margin of the 
lower and anterior edge of the glenoid fossa, but by rotating the arm 
outwards it immediately resumes its place. I found the whole limb 
as fully developed, and he said it was quite as strong, as the opposite 
limb. 

I have already mentioned the case of Mrs. Hunn, whose arm had 
been dislocated more than twenty times in the last five years; and I 
remember a lad, Pat Dolan, aged nineteen years, whose left arm was 
dislocated by falling from the masthead of a vessel, and hanging by 
his hand. No attempt was made to reduce it until fourteen hours after 
the accident, at which time it was set by two German doctors, but not 
until they had pulled upon it three hours. Four months after, it was 
again dislocated by the slipping of an oar while he was rowing a boat. 
A surgeon having failed this time to bring it into place, I succeeded 
readily, and without the aid of an anaesthetic, by raising the arm di- 
rectly upwards in the line of the body, while my foot was pressed upon 
the top of the scapula. Many other similar examples have come under 
my notice. 

We have referred more than once to the occasional difficulty of 
diagnosis in this as well as in many other shoulder accidents ; and I 
have alluded to five cases in which the dislocation was not recognized, 
but none of them had been seen by a surgeon. Other writers have, 
however, mentioned many examples of unreduced dislocations of the 
shoulder, for which surgeons of skill and experience were responsible. 
I have myself met with these cases quite often. For example, I have 
seen two dislocations of the humerus into the axilla, both of which 
had been seen and examined by New York hospital surgeons within a 
few hours after the receipt of the injury, but the nature of the accident 



582 DISLOCATIONS OF THE SHOULDER. 

had not been recognized. One of these I reduced at Bellevue Hospital 
on the seventh day, and one on the tenth. There was also presented 
to me, at the Charity Hospital (Blackwell's Island), in my service, an 
axillary dislocation of twenty years' standing, which a surgeon saw 
immediately after the receipt of the injury and failed to recognize. In 
other cases the dislocation has been clearly made out, but the surgeon 
has been unable to reduce the bone. It has been my fortune to succeed 
in several instances where others have made a fair trial and have failed, 
but the following case leaves me no opportunity to boast the superiority 
of my own skill above that of my confreres. 

Mary Kanally, set. 49, a large, fat, laboring woman, was admitted 
into the Buffalo Hospital of the Sisters of Charity, with a dislocation 
of the right humerus into the axilla, which had occurred twelve hours 
before. This is the same woman of whom I have before spoken as 
having produced the dislocation by a fall while holding upon the 
handle of a pump. 

Drs. Lockwood and Baker, of Buffalo, were first called, and attempted 
reduction. They made extension and counter-extension in every pos- 
sible direction, and for a long time, but to no purpose. She was then 
sent to the hospital. Without attempting to describe minutely the 
various modes of extension and manipulation which I employed, I 
will briefly state that, having placed her completely under the influ- 
ence of chloroform, the manipulations were made assiduously during 
one hour, without success. On the following morning she was bled 
freely from the opposite arm, and chloroform again administered; ex- 
tension being made, in the presence of Prof. Charles A. Lee and other 
gentlemen, with Jarvis's adjuster. After more than an hour, the effort 
was again suspended. On the following day we made a third attempt, 
the patient being completely under the influence of chloroform, but 
with no better success. The chloroform produced a condition approach- 
ing apoplexy, and it was not again used. On the tenth day, assisted 
by Prof. James P. White and other surgeons, we applied the compound 
pulleys, moving the arm in various directions. Twice we thought the 
reduction was accomplished, but as often as we proceeded to examine 
it attentively we found it was not. If it did ever pass into the socket, 
it was immediately displaced. 

The woman after this refused to submit to any further attempts, and 
she soon left the hospital, nor have I seen or heard from her since. 

Sir Astley Cooper has thus described the appearances presented on 
dissection of a dislocation which had been long unreduced: "The head 
of the bone altered in its form ; the surface towards the scapula being 
flattened. A complete capsular ligament surrounding the head of the 
os humeri. The glenoid cavity entirely filled by ligamentous matter, 
in which were suspended small portions of bone, which were of new 
formation, as no portion of the scapula or humerus was broken. A new 
cavity formed for the head of the os humeri on the inferior costa of 
the scapula; but this was shallow, like that from which the bone had 
escaped." 

When the dislocation into the axilla remains unreduced, the conse- 
quences are always sufficiently grave, but they differ very much in de- 



DISLOCATION OF THE SHOULDER DOWNWARDS. 



583 



Fig. 260. 




New socket, in an ancient luxation of 
the shoulder downwards. (From Sir A. 
Cooper.) 



gree, in character, and in persistence, according as the arm has remained 
a longer or shorter time unreduced, and according to the presence or 
absence of complications. These condi- 
tions will be best illustrated by a refer- 
ence to examples. 

Wm. S., a German, set. 51, fell down 
a flight of steps while intoxicated, pro- 
ducing a dislocation of the left arm into 
the axilla. Eleven hours after the ac- 
cident he was received into the Buffalo 
Hospital of the Sisters of Charity. No 
attempt had been made to reduce the 
bone. The reduction was effected by 
myself with tolerable ease, by extend- 
ing the arm perpendicularly above the 
head, while my foot pressed upon the 
top of the scapula. The head of the 
humerus could be plainly felt in the 
axilla, approaching the socket, until it 
seemed to be directly over it, when, on 
lowering the arm, it was found to be 
reduced. After the reduction the patient 

could not raise the arm more than eight inches from the body. The 
fingers, hand, and forearm were almost paralyzed. Three weeks later, 
when he left the hospital, his arm had improved, but he could not flex 
his fingers. 

Mrs. G., set. 70, fell down a flight of steps and dislocated her arm 
into the axilla. She did not suspect the nature of the injury, and no 
surgeon w T as called. I was consulted one week after the accident, at 
which time she was suffering great pain from the pressure of the head 
of the bone upon the axillary nerves. We first attempted to reduce 
the bone by resting the knee in the axilla while she w T as sitting, but 
without success. We then placed her in bed, and with my knee in 
the axilla, the acromion process being supported by the hands of an 
assistant, we restored the bone after a few moments of pretty firm ex- 
tension downwards and outwards. After the reduction she could not 
raise her arm, but the pain was much abated. One month later the 
arm remained very weak. She could not raise it more than six inches 
toward her head, but I could raise it to a right angle with the body 
without causing pain. The whole hand felt numb, and was occasion- 
ally painful. The deltoid muscle was slightly atrophied. There was 
also a slight flatness under the acromion process behind, and on the 
outer side, with a corresponding fulness in front. 

Mary Ann Hasler, set. 47, was admitted to the hospital with a dis- 
location of the right humerus into the axilla. The arm had been dis- 
located three weeks, in consequence of a fall upon the upper and outer 
part of the shoulder. An empiric, who saw T it fifteen minutes after the 
fall, and when the arm w T as not swollen, said it was not dislocated. 
On the fifth day a Catholic clergyman discovered that it was out, and 
attempted to reduce it, but was not successful. When she came under 



584 DISLOCATIONS OF THE SHOULDER. 

my notice the arm was lengthened about one-quarter or one-half of an 
inch, and hung out from the body in a condition of almost complete 
paralysis. There was very little swelling about the shoulder or arm, 
and the head of the bone could be distinctly felt in the axilla. The 
patient being rendered partially insensible by chloroform, I placed my 
heel in the axilla, and by pulling moderately about thirty seconds in a 
direction slightly outwards from the line of the body, the bone was 
reduced. Seven days after the reduction she left the hospital, the arm 
being yet quite useless, though not greatly swollen. There was also a 
striking fulness in front of the head of the bone. 

Wm. Gardner, of Painted Post, N. Y., set. 75, dislocated the right 
humerus into the axilla, twenty years before I saw him, by falling upon 
his hands with his arms extended. I found the arm weak and atro- 
phied, so that he could raise it but slightly outwards from his side ; 
he was unable to move it forwards much beyond the line of his body, 
but he could carry it back quite freely. The whole hand was in a 
condition of partial insensibility. 

I have before mentioned the case of Maria Norrigan, the Swiss 
woman, whose arm had been dislocated downwards seventeen years. 
The deltoid muscle has become greatly wasted ; the head of the bone 
can be felt obscurely in the axilla; the arm is shortened perceptibly; 
the elbow hangs freely against the side; the little and ring fingers are 
numb, and also one-half of the forearm; the whole hand and arm are 
weak and atrophied ; she complains also occasionally of a troublesome 
sensation of formication over the arm and hand ; she cannot straighten 
her fingers perfectly ; the elbow may be raised from the side to a right 
angle with the body, but she cannot raise it herself more than one foot; 
she carries it back a little more freely than forwards. 

In compound dislocations the prognosis must always be regarded as 
exceedingly grave. In the only example which has come under my 
notice, the circumstances attending which I shall hereafter mention in 
the general chapter devoted to compound dislocations, the patient died 
from sloughing of the axillary artery. Mr. Scott has, however, re- 
ported a case, in a boy fourteen years of age, who recovered rapidly 
after the reduction was effected, and in thirteen months his arm was 
nearly as useful as before. 1 

Treatment. — The principles of treatment in this dislocation are very 
simple and easy to be comprehended. I speak now of recent uncom- 
plicated cases of dislocation into the axilla; and, notwithstanding the 
various and sometimes almost contradictory views which surgeons have 
entertained as to the best and most rational modes of procedure, I 
continue to affirm that the laws which are to govern the reduction in 
a great majority of cases are established and indisputable. 

Observe now the obvious anatomical facts, and then consider the 
inevitable inferences. 

The capsule is torn, generally extensively, along the inner and lower 
margins of the socket. The head of the bone is lodged below and 

1 Scott, Amer. Journ. of Med. Sci., vol. xx, p 515, Aug. 1837, from the London 
Lancet for March 4, 1837. 



DISLOCATION OF THE SHOULDER DOWNWARDS. 585 

slightly in advance of its natural position, in consequence of which the 
points of origin and insertion of the deltoid muscle and the supra- 
spinatns are separated somewhat and their fibres rendered tense, inso- 
much that the arm is abducted and actually lengthened. 

At first, and in the most simple cases, these are the only muscles 
which are in a state of extreme tension, but after the lapse of a few 
hours, or of a few days, nearly all the other muscles about the joint, 
most of which were originally only in a condition of moderate exten- 
sion, and some of which were rather relaxed than extended, sympathize 
with those which are suffering the most, and a general contraction and 
rigidity ensue, increased also at the last by the supervention of inflam- 
mation and its consequences. 

What, from these simple premises, must be the obvious practical 
deductions? 

That in the simplest forms of the dislocation the most rational mode 
of reduction will be to elevate the arm sufficiently to relax the over- 
strained deltoid and supraspinatus muscles, which bind the head of 
the bone in its new position, and to pull gently in the same direction, 
in order to overcome the moderate resistance offered by several other 
muscles, but whose tension cannot be relieved by the same manoeuvre. 

Failing in this, that we shall increase the relaxation of the first 
named muscles, by pulling at a right angle with the body, or even 
directly upwards ; and meanwhile, as we carry the arm more and more 
upwards, we shall operate more powerfully against the resistance of the 
other muscles. 

If in all these modifications of the same procedure, we keep the arm 
a little back of the axis of the body, we shall accomplish the indica- 
tions the most perfectly. 

Such are the conclusions which must be drawn from the anatomical, 
or, as Mr. Pott would call it, the "physiological/' argument; and which 
assumes as its basis that the muscles constitute the sole or the main 
obstacle to the return of the bone to its socket. If any surgeon main- 
tains that the premise is unsound, and that the restoration of the head 
of the bone is opposed by the untorn fibres of the capsules or by any 
other important circumstance than the action of the muscles (we speak 
of ordinary cases), we shall content ourselves by referring him again 
to the extensive laceration which this capsule generally suffers, and 
to the constrained and almost uniform position of the arm, as a suffi- 
cient reply to his objection. 

It must not be forgotten that in all these modes of extension, for with 
nearly all of them some slight degree of extension is found necessary, 
there must be afforded some point of resistance beyond the bone; and 
this it is really which has constituted one of the greatest impediments 
to reduction. It is not that the muscles are in such an extraordinary 
state of extension or rigidity that they must be operated against with 
great force; it is not that the margin of the glenoid fossa is an elevated 
barrier, like the margin of the acetabulum, over which the bone must 
be lifted before it can fall into its socket; but the explanation of the 
difficulty so often experienced in producing effective extension and 
counter-extension is to be sought for mainly in the fact that the scapula, 

38 



586 DISLOCATIONS OF THE SHOULDER. 

upon which the humerus rests, is movable, being held to the body by 
little else than muscles, which, in fact, bind the scapula much less 
firmly to the body than the muscles of the shoulder now bind the 
scapula to the arm ; while at the same time the scapula itself presents 
very few points against which a counter-extending force can be properly 
and efficiently applied. 

Occasionally it will be only necessary to elevate the arm to an acute 
angle, or to a right angle with the body, when, the resistance of the 
deltoid and supraspinatus being overcome, the bone will at once re- 
sume its place. In several instances which have come under my notice 
nothing more has been necessary ; and where it can be done, the least 
possible pain and injury are inflicted. It is the method, therefore, 
which in all recent cases I have first tried and would wish to recom- 
mend. By it I have more than once succeeded when other and more 
violent efforts have failed. 

At other times it will be necessary to add to this simple manipula- 
tion only a moderate degree of extension, such as the hands of the 
surgeon can make, without the application of direct counter-extension 
except what is effected by the weight and resistance of the body. 

Dr. John T. Darby, Professor of Surgical Anatomy in the Univer- 
sity, city of New York, informs me that he has been very successful in 
reducing dislocations of the shoulder, by adopting a rule similar to that 
which we have laid down in reducing dislocations of the thigh, namely, 
to carry the arm only in those directions in which it meets with the 
least resistance. He has found that, in most cases, he can carry the 
arm up to nearly or quite a perpendicular, by humoring the action of 
the muscles; and that in this position the reduction is easily effected. 
I have no doubt that the principle, as stated by Professor Darby, is 
sound, and that in nearly all dislocations the same may be applied 
successfully, whenever we depend upon manipulation alone. 

If, however, the bone refuse to move, we shall then be obliged to 
consider upon what point and by what means we can best apply a 
counter-extending force. Ample experience has taught me that the 
extremity of the acromion process is the only available point when we 
are making the extension in a line below a right angle, or in a line 
downwards more or less approaching the axis of the body. It has been 
supposed that the counter-extension could be made in the axilla against 
the inferior margin of the scapula ; but several obstacles are presented 
to the successful application of force at this point. The axillary space 
is narrow and deep, so that even with the ingenious contrivance of 
placing first a ball of yarn in the axilla, and upon this the heel of the 
operator, it will be found exceedingly difficult to enter the axilla with- 
out at the same time pressing with considerable force against its mus- 
cular margins; but to press upon the pectoralis major and latissimus 
dorsi is to neutralize our own efforts. If, however, the heel or the ball 
does press fairly into the axilla, it will not find the scapula readily, but 
it must impinge first upon the head of the humerus, which is always a 
little to the inner side of the scapula. If it ever is made to reach 
actually the inferior border of the scapula, and I do not think it is, the 
effect must be still only to tilt the scapula upon itself by throwing back 



DISLOCATION OF THE HUMERUS DOWXTAEDS. 587 

its lower angle, and not to separate the glenoid cavity or its upper and 
anterior margin from the head of the humerus. 

Whatever success, therefore, may have attended this mode of prac- 
tice, either in my own hands or in the hands of other surgeons, must 
be ascribed not to the counter-extension thus effected, but simply to 
the operation of the heel as a wedge, which, by insinuating itself be- 
tween the body and the head of the bone, has thrust it outwards and 
upwards into its socket ; or to its having acted as a fulcrum upon which 
the humerus has operated as a lever. 

It is to the extremity of the acromion process, then, that we must 
apply our counter-extension when we are employing this mode of ex- 
tension. The fingers or hands of a faithful assistant may answer the 
purpose, or having removed his boot, the operator may often press 
successfully with the ball of his foot, and the more he carries the arm 
outwards, the more secure will be his seat upon the process ; or we 
pay adopt some of the contrivances for securing the process which 
have been suggested by other surgeons ; such as a band crossing the 
shoulder, and made fast to a counter-band, which passes through the 
armpit and against the side of the body. Dr. Physick, of Philadelphia, 
reduced a dislocation in this way as early as the year 1790, in the case 
of a patient admitted to St. George's Hospital, in London, while he 
was a student of medicine, and he subsequently taught the same in 
his lectures. Physick directed that an assistant should press firmly 
against the process with the palm of his hand. Dorsey and Hays 
approve of the same method, 1 and perhaps a majority of American 
surgeons regarded it favorably. 

If we pull directly outwards, at a right angle with the body, we 
may still continue to press upon the acromion process with the foot ; 
or we may perhaps trust to the method of making counter-extension, 
first suggested by ISathan Smith, of Xew Haven, and subsequently 
recommended by his son, Prof. Xathan P. Smith, of Baltimore. Says 
Prof. X. P. Smith : 2 " What surgeon of experience has not encountered 
the difficulty which almost always occurs in fixing the scapula?" and 
he then proceeds to give what seems to him the most effectual mode 
of rendering the scapula immovable, namely, to make the counter- 
extension from the opposite wrist. By this method the trapezii are 
provoked to contraction, and the scapula of the injured side is drawn 
firmly toward the spine and the opposite scapula. In illustration of 
the value of this procedure he relates the case of a gentleman who 
had suffered a dislocation of his left shoulder, and upon whom an un- 
successful attempt at reduction had already been made by a respectable 
surgeon. Dr. Smith being called, proceeded as follows : Two gentle- 
men made counter-extension from the opposite wrist, while Dr. Smith 
and Dr. Knapp made extension from the wrist of the injured side, at 
first pulling it downwards, but gradually raising it to the horizontal 

1 Physick, Amer. Journ. Med. Sci., vol. xix, p. 386, Feb. 1837. Dorsey's Ele- 
ments of Surgery, vol. i, p. 214. Philadelphia, 1813. 

2 Smith's Med. and Surg. Memoirs, Baltimore, 1831, p. 337 ; also, Amer. Journ. 
Med. Sci., July, 1861 ; also, American Med. Times, Nov. 9, 1861 ; paper by Stephen 
Rogers, M.D. 



588 



DISLOCATIONS OF THE SHOULDER. 



direction, and then gently depressing the wrist. On the effort being 
steadily continued for two or three minutes, the bone was observed to 
slip easily into its place. 

But no position places the scapula so completely under our control 
as that in which the arm is carried almost directly upwards, and the 
foot is placed upon the top of the scapula. By this method we may suc- 
ceed generally when every other expedient has failed, yet it is painful; 



Fig. 261. 




N. R. Smith's method. 

and I cannot but think that it increases the laceration of the capsule, 
and that, even when employed in recent cases, it does sometimes serious 
injury to the muscles about the joint. In Lister's case of rupture of 
the axillary artery, and in Agnew's case of rupture of the axillary vein, 
both of which will again be referred to in connection with ancient dislo- 
cations, the accidents occurred when the arm was drawn upwards. La 
Mothe was the first to recommend this method, 1 but as early as the year 
1764, Charles White, of Manchester, made fast a set of pulleys in the 
ceiling, and, placing a band around the wrist of the dislocated arm, he 
drew the patient up until the whole body was suspended. No pressure, 



1 La Motlie, Amor. Jonrn. Med. Sci., vol. xix, p. 387, Nov. 1836, from Melanges 
de Med. et Chir., Paris, 1812. 



DISLOCATION OF THE HUMERUS DOWNWARDS. 589 

however, was made upon the scapula from above, which is uo doubt 
the most essential part of the process. 1 By La Mothe's plan, Jobert 
succeeded after twenty-three days when all the usual methods had 
failed. 2 Sometimes this procedure is modified by placing the hand of 
the operator against the top of the scapula, as is shown in the accom- 
panying drawing (Fig. 262) ; and I have several times succeeded in this 
way after other measures have failed. 

Fig. 262. 




La Mothe's method, modified. 



A gentle movement backwards or forwards, a slight rotation of the 
limb, or suddenly dropping the arm toward the body, diverting the 
attention of the patient, are little tricks of the operator, which now 
and then prove successful. 



Fig. 263. 




Sir Astley Cooper's method of applying extension with the heel in the axilla. 

Sir Astlev Cooper thus describes his method of applying the heel to 
the axilla (Fig. 263) : 



1 C. White, Amer. Journ. Med. Sci., Nov. 1836, from Med. Obs. and Inquiries, 
vol. ii, p. 273, London, 1764. 

2 Ibid., vol. xxiii, p. 237, Nov. 1838. 



590 



DISLOCATIONS OF THE SHOULDER. 



Fig. 264. 



" The patient should be placed in the recumbent posture, upon a 
table or sofa, near to the edge of which he is to be brought ; the sur- 
geon then binds a wetted roller around the arm immediately above the 
elbow, upon which he ties a handkerchief; then he separates the pa- 
tient's elbow from his side, and, with one foot resting upon the floor, 
he places the heel of his other foot in the axilla, receiving the head of 
the os humeri upon it, whilst he is himself in the sitting posture by 
the patient's side. He then draws the arm by means of the handker- 
chief, steadily, for three or four minutes, when, under common circum- 
stances, the head of the bone is easily replaced ; but if more force be 

required, the handkerchief may be 
changed for a long towel, by which 
several persons may pull, the sur- 
geon's heel still remaining in the ax- 
illa. I generally bend the forearm 
nearly at right angles with the os 
humeri, because it relaxes the biceps, 
and consequently diminishes its re- 
sistance." 

He was also accustomed in some 
cases to reduce the dislocation by 
substituting the knee for the heel. 
Placing the patient upon a low chair, 
the axilla is laid over the knee of the 
operator, and while one hand steadies 
the acromion process and scapula, the 
other presses downwards upon the 
lower end of the humerus (Fig. 264). 
If some hours or days have elapsed 
since the occurrence of the disloca- 
tion, it will be necessary to resort to 
chloroform or ether for the purpose 
of paralyzing the muscles, as well as 
with the view of preventing pain; and it may be necessary, in addition, 
to resort to pulleys, or to some similar permanent mode of extension. 
The same measures also sometimes become necessary in very recent 
cases, especially in muscular subjects. 

In employing the pulleys we generally operate, not exactly in a line 
with the axis of the body, nor at more than a right angle, but between 
an angle of 45° and a right angle. 

Mr. Skey has suggested a plan by which we may combine the prin- 
ciple of the heel in the axilla with the pulleys, but which plan would, 
in my judgment, be very much improved by a counter-extending force 
applied to the acromion process. I ought to say, however, that Mr. 
Skey prefers that the scapula should not be fixed, believing that the 
reduction is much more easily effected when the glenoid cavity is drawn 
downwards in the act of making the extension. 

With all respect for the opinion of this distinguished surgeon, we 
cannot precisely agree with him ; and while we would be disposed to 
recommend in some cases a trial of his method of applying the pulleys, 




Sir Astley Cooper's method of operating 
with the knee in the axilla. 



DISLOCATION OF THE HUMERUS DOWNWARDS. 



591 



we would, at the same time, or certainly in the event of its failure, add 
the acromial support, and especially would we advise that the arm 
should be more abducted. The following is Mr. Skey's method, as 
described by himself: 

" There is no reason why, in very muscular subjects, or in old dis- 
locations, the same principle may not be applied conjointly with the 



Fig. 265. 




Iron knob employed by Skey, instead of the beel. 

use of pulleys. For the purpose of retaining this admirable because 
most efficient principle, I employ a well-padded iron knob, which may 
represent the heel, from which there extend laterally two strong straight 
branches of the same metal, each ending in a bulb or ring of about 
four inches in length, the office of which is designed to keepthe mar- 
gins of the axilla as free from pressure as possible." The iron knob 
is to be pressed well up into the axilla and attached to cords fastened 
to a staple ; the patient lying upon his back or inclined a little to the 
opposite side. The arm is then to be drawn downwards by the pulleys, 
"as nearly as possible parallel to, and in contact with, the body.'' 1 

In this way Mr. Skey says that he has succeeded in reducing a 
great many dislocations, whether occurring in very muscular men, or 
after some days', or weeks', or even months' duration ; and he thinks 



Fig. 266. 




Skey's method of making extension and counter-extension with pulleys. 

the plan especially applicable to cases which require long and persistent 
extension. 

Mr. Skey and many other surgeons prefer to make the extension 
from the hand. I have succeeded as well, and it has seemed to be less 
painful to my patients, when I have followed the practice of Sir Astley, 

1 Skey, Operative Surgery, Amer. ed., p. 93. 



592 



DISLOCATIONS OF THE SHOULDER. 



and made the extension from the arm. Sir Astley always made the 
extension more or less out from the line of the body, and generally 
almost at a right angle when using the pulleys, the scapula being made 
fast bv "a girt buckled on the top of the acromion," or by a split 
cloth (Fig. 267). 



Fig. 267. 




Sir Astley Cooper's mode of making extension with pulleys. 



The instrument invented by Dr. Jarvis, of Portland, Conn., called 
the adjuster, useless and even mischievous as we have found it in its 
application to the treatment of fractures, possesses considerable merit 
as an apparatus for reducing old dislocations, especially of the shoulder. 
The principal advantage which may be claimed for it is, that while 
the forces are being applied the limb may be moved pretty freely in 
all directions ; thus enabling us to employ rotation at the same time 
that the extension is made. We may also lift or depress, adduct or 
abduct the limb without relaxing the extension. In the hands of 
American surgeons it has occasionally been successful when other means 
have failed. Dr. Jarvis has related a case presented at the Marine 
Hospital, at Mobile, Alabama, of forty-two days' standing, which he 
reduced on the second attempt, after other means had failed ; l and Dr. 
May, of Washington, reduced a similar dislocation at the end of six 
weeks, by the same apparatus, without, however, having previously 
resorted to any other means. 2 

I have myself used the apparatus occasionally, both in my hospital 
and private practice, and can speak favorably of its operation. 

I must not omit to mention the practice adopted by Prof. H. H. 
Smith, of Philadelphia, according to whom nearly all dislocations of 
the shoulder, of a recent date, may be promptly and easily reduced by 



1 Boston Med. and Surg. Journ., vol. xxxix, p. 215. 2 lb., vol. xxxv, p. 454. 



DISLOCATION OF THE HUMERUS DOWNWARDS. 593 

manipulation alone. His method consists, first, in flexing the forearm 
upon the arm, while, at the same moment, the elbow is lifted from the 
body; second, in rotating the humerus upwards and outwards, employ- 
ing the forearm as a lever ; and third, in reversing this last movement, 
that is, rotating the humerus downwards and inwards while at the 
same moment the elbow is carried again to the side. 1 

When the dislocation is into the axilla, this manoeuvre will gener- 
ally succeed; but if the head of the humerus has slipped forwards, even 
only sufficient to engage itself slightly under the tendons of the coraco- 
brachialis and biceps, the outward rotation of the humerus will inevi- 
tably thrust the head further forwards, and fasten it more certainly 
underneath these tendons ; while the rotation of the humerus in the 
opposite direction will alone often be sufficient to carry the head directly 
into the socket. 

Ancient Luxations. — Finally, I ought to speak somewhat more in 
detail of the manner of procedure and of the principles involved in the 
reduction of old dislocations, or of dislocations requiring the interposi- 
tion of mechanical appliances ; especially with a view to the more com- 
plete exposition of my own practice in these cases. 

If the dislocation is recent, but reduction is found impossible with- 
out the aid of mechanical apparatus, the difficulty will be understood 
to consist mainly, if not altogether, in the resistance offered by the mus- 
cles. If, in a few exceptional cases, the capsule, or an untorn tendon, 
or the margin of the glenoid fossa, present themselves as obstacles, 
they must still be considered as unusual and extraordiary impediments, 
the existence of which may be regarded rather as possible than prob- 
able. 

Almost our sole purpose, then, it will be understood, in all recent 
cases requiring mechanical appliances, and in some ancient . cases, is to 
overcome the contraction of the muscles. 

We prefer always to place the patient upon a mattress laid upon the 
floor ; two silk handkerchiefs, or two pieces of a cotton roller, are then 
laid along the radial and ulnar sides of the humerus, and over the 
middle of these, immediately above the condyles, a wetted roller is 
applied, its end being made fast with a needle and thread rather than 
with a pin. The upper ends of the longitudinal strips, or of the hand- 
kerchiefs, are now turned down and tied to the opposite ends, thus con- 
verting them both into lateral loops. For the purpose of making coun- 
ter-extension, a sheet is passed around the body under the axilla, and 
made fast to a staple ; while an intelligent assistant is to manage the 
scapula with his naked hands, either by pulling with his fingers placed 
under the process, or by pushing with the palm of his hand and ball 
of his thumb. The pulleys, secured to a staple exactly opposite to that 
which holds the counter-extending band, are made ready, but not for 
the present attached to the arm. 

As soon as the patient is placed completely under the influence of an 
anaesthetic, the operator is ready to proceed with the reduction. It is 
my maxim never to attempt to accomplish by complicated and violent 

1 H. H. Smith, Gross's Surg., ed. of 1863, p. 152. 



594 DISLOCATIONS OF THE SHOULDER. 

measures what may be done as well by more simple and gentle means. 
I think it proper, therefore, to make several attempts at reduction by 
manipulation alone, aided now by the anaesthetic, the extending and 
counter-extending bands, etc., before resorting to the pulleys. Seating 
himself upon the mattress, with his boots drawn, the surgeon should 
bend the forearm to a right angle with the arm, and planting one heel 
in the axilla, with one hand he should seize upon the loops at the elbow, 
and with the other steady the hand and forearm of the patient, while 
he proceeds to make firm traction for a few seconds in the line of the 
body, or only a little out from this line. Failing in this, he may direct 
the assistant to seize upon the scapula, and make counter-extension ; 
still not succeeding, he may change his foot from the axilla to the acro- 
mion process and pull directly outwards at a right angle with'the body, 
or he may swing himself gradually around until he comes to be above 
the head of the patient, and the foot presses firmly upon the top of the 
scapula ; now descending again in the same direction, he will very prob- 
ably find the limb reduced, or capable of being reduced easily, by oper- 
ating upon it as a lever by laying it across the body while at the same 
moment it is rotated slightly inwards. 

If still the reduction is not accomplished, the pulleys must at once 
be put in requisition. The sheet passed around the chest and fastened 
to a staple, is only a means of supporting the body and rendering it 
more steady ; as a means of counter-extension its value is inconsider- 
able. To make fast the scapula, we must still rely mainly upon the 
naked hands of strong men, or upon a strap drawn firmly across the 
process and held in place by an assistant. 

Whenever we employ extension without the aid of anaesthetics, as 
sometimes we are compelled to do, it must be constantly borne in mind 
that it is proposed to conquer the muscles by fatiguing them, and that 
this cannot be done by a force suddenly applied, however great it may 
be, but only by gentle, steady, and long-continued extension. The 
muscles, when attacked openly and vigorously, resist, and will suffer 
laceration rather than yield, while, on the other hand, an insidious but 
persevering approach seldom fails to end in their defeat. The same is 
true, but in a much less degree, when the patient is insensible from an- 
aesthesia. 

The forearm is again flexed, and the arm carried out to a right angle 
with the body, the pulleys secured to the loops, and the assistant takes 
hold upon the process, while the surgeon draws gently upon the rope 
attached to the pulleys; as soon as everything is moderately tense, he 
is to desist for a few moments. Again the rope is drawn upon gently, 
and again the progress of the extension is suspended. In this way the 
operator is to proceed during half an hour, or two hours, as the nature 
of the case may demand ; occasionally rotating the humerus, and occa- 
sionally lifting its head toward the socket. Meanwhile, it is under- 
stood that the principal counter-extension is made by the assistants, 
who must relieve each other, at the acromion process. The sheet in 
the axilla, or rather against the side of the chest, has some value in 
this respect when the arm is at a right angle with the body, but in 
itself it cannot control the scapula, only as it holds the body to which 



DISLOCATION OF THE HUMERUS DOWNWARDS. 595 

the scapula is attached. Much, therefore, as we may regret the incon- 
venience of making counter-extension by hands alone, experience and 
anatomy alike must teach that here it is the only mode. If these dis- 
locations are reduced often by other methods, as no doubt they are, 
then it is only an evidence that in these examples little or no counter- 
extension was necessary. 

Sometimes the dislocation is not reduced when the extension is given 
up, but if then a resort is promptly made to some one of the simple 
methods already described, while the muscles are still exhausted, it 
very often happens that the reduction is easily accomplished. 

It will be prudent in all cases, in order to prevent a reluxation, 
whether the dislocation is recent or ancient, as soon as its reduction is 
effected, to place the arm in a sling and secure the elbow to the side by 
a few turns of a roller. I do not think the axillary pad necessary, and 
I am afraid it has sometimes done as much mischief as the dislocation 
itself. 

The following example will illustrate the variety of expedients to 
which we are obliged sometimes to resort before our efforts prove suc- 
cessful : 

Thomas Leeding, of Niagara Co., N. Y., set. 52, a laborer, and a 
muscular man, dislocated his right arm into the axilla, by jumping 
from the cars when they were in full motion. The blow was received 
upon the shoulder. An intelligent country surgeon, assisted by several 
other persons, attempted reduction within an hoar after the accident, 
but failed, and as the patient had some distance to travel, he was not 
brought under my notice until eighteen hours had elapsed. We first 
administered chloroform, and then, while an assistant held firmly upon 
the acromion process, I pulled in the line of the body, then outwards, 
and finally upwards, but to no purpose. Having then applied Jarvis's 
" adjuster," and after the arm had been kept extended at a right angle 
with the body fifteen minutes, w r e removed the apparatus, and found 
the bone in its place. 

John Harrington, set. 50, a very large and powerful man, fell, while 
intoxicated, and dislocated his left humerus into the axilla. No sur- 
geon was called until the tenth day, when he first consulted Dr. Dud- 
ley, who at once brought him to me. Without delay we applied the 
pulleys, and placing the arm at a right angle with the body, we made 
extension fifteen minutes; occasionally also rotating the arm. We 
then removed the pulleys, and while an assistant held upon the acro- 
mion process, with my heel in the axilla, I made extension in the line 
of the axis of the body, then outwards, and finally upwards with my 
foot upon the top of the scapula. I next seated my patient in a chair, 
and drew his arm and axilla forcibly over my knee. The bone was 
not yet reduced ; I therefore bled him twenty-four ounces, or until 
partial syncope was induced, and proceeded to repeat most of these 
processes, but with no better result. At this moment I determined to 
use sulphuric ether, which had just been introduced as an anaesthetic, 
and while he was completely under its influence the pulleys were again 
applied, and the extension continued for some time, and until the rope 



596 DISLOCATIONS OF THE SHOULDER. 

broke. He was then again placed in a chair, and the axilla brought 
over my knee, when in a moment the reduction was accomplished. 

Julia McKnight, set. 39, admitted to ward 28, Bellevue, in Novem- 
ber, 1866, with a dislocation of the humerus into the axilla, which had 
existed seven weeks and one day. The deltoid was much wasted and 
the hand somewhat numb. Before the class of medical students, the 
patient being under the influence of ether, the reduction was effected; 
but not until various methods of manipulation and extension had been 
tried and had failed. Having finally carried the arm directly upwards 
— La Mothe's method — and in this position employed extension, the 
arm was again brought down and with moderate manipulation the re- 
duction was effected. The return of the bone was sudden, and was 
accompanied with a slight grating sensation ; it was observed also, that 
a hard bony projection was left in the axilla, which was no doubt the 
margin of a new socket. The head of the humerus could be plainly 
seen and felt in its socket, rendering it certain that we had not broken 
the surgical neck of the humerus. 

John Bowles, of Buffalo, aged 45 years, an Irish laborer, tolerably 
muscular, but spare. Bowles fell down a flight of stairs, and dislocated 
his left humerus into the axilla. The shoulder became much swollen, 
and was very painful, but he did not suspect a dislocation and did not 
consult a surgeon. Eight w r eeks after the accident he applied to me. 
There were present the usual signs of this dislocation, but the arm was 
by careful measurement one inch and a half longer than the other. 

The reduction was accomplished on the same day, in presence of 
Drs. Lee, Webster, Coventry, Ford, and Jewett. The time occupied 
in the reduction was about two hours. An attempt was first made 
with the heel in the axilla and with violent rotation and extension. 
The same plan was repeated with the aid of ether, which w T as adminis- 
tered freely. Jarvis's adjuster was now applied, with no result, except 
that, either in consequence of the force employed by the adjuster, or in 
consequence of the free use of ether, or of both, he became convulsed 
violently, which was accompanied by frothing at the mouth and other 
grave symptoms. The adjuster was removed, and the exhibition of 
ether discontinued. As soon as the convulsions ceased, and before 
consciousness had returned, extension, rotation, etc., were again made 
by hands. Finally, after all extension was relinquished, placing my 
knee in the axilla, I reduced the bone by a very slight rotary action 
upon the arm; the bone was at once plainly in its socket, but the 
unusual length of the limb continued, being one inch and a half longer, 
though it could be shortened to the same length as the other by lifting 
the elbow. A pad was placed in the axilla, and the arm secured with 
a sling and roller. The next day the arm remained in place, but it 
was now only one inch longer than the other. At the end of a fort- 
night it was only three-quarters of an inch longer, and could be re- 
duced to the same length by lifting; the pain and swelling about the 
shoulder, which never were great, were subsiding, and the patient was 
dismissed. 

However skilfully our efforts may be directed, they w r ill be found 
occasionally to fail ; either owing to adhesions which have taken place 



DISLOCATION OF THE HUMERUS DOWNWARDS. 597 

between the head of the bone, or rather its capsule, and the adjacent 
tendons, muscles, etc., to some extraordinary position of the head and 
neck of the bone in its relation to ligamentous or tendinous structures, 
to a filling up of the glenoid fossa, or to some other cause not fully 
explained. Such failures have happened not only in the hands of 
ignorant and unskilful surgeons, destitute of appliances, but also in the 
hands of those who are the most expert, and who are the most com- 
pletely provided with all the necessary apparatus. Indeed, if the truth 
were known, it would probably be found that the number of failures 
after the sixth or eighth week has been greater than the successes. The 
records of surgery, however, furnish a great many examples of ancient 
dislocations of the humerus reduced after periods ranging from one 
month to six, or even longer. . Dieffenbach has been able to accom- 
plish the reduction of a forward dislocation after two years, but not 
until he had cut the tendons of the pectoralis major, latissimus dorsi, 
teres major, and teres minor, and had divided the ligaments surround- 
ing the newjoint. 1 

It would be unjust to the young surgeon not to call especial atten- 
tion to the numerous examples of serious and even fatal accidents 
which have followed upon the attempts to reduce ancient luxations at 
this joint. 

Rupture of the Axillary Artery. — The late George C. Black man, of 
Cincinnati, a distinguished surgeon, having met with one of these un- 
fortunate accidents in his own practice, has had the candor to make a 
public statement of the case and of the circumstances which attended 
it. In a letter to the editor of the Western Lancet, published in the 
November number for 1856, he writes as follows: 

" About the 10th ult., aided by yourself, I succeeded in reducing by 
manipulation, without the pulleys, a dislocation into the axilla, of 
eighty days' standing. The reduction was accomplished in a very few 
minutes, under the influence of chloroform and ether, and the next 
morning the patient left for the country, in a comfortable condition. 
Since that I have received no tidings from him. Encouraged by the 
result in this case, another patient, himself a physician, a tall, athletic 
man, and about fifty years of age, decided to submit to the same manip- 
ulation, although his arm had been dislocated for about sixteen weeks. 
The dislocation was downwards and inwards, and about the tenth week 
an unsuccessful attempt, by another surgeon, had been made with the 
pulleys, to which the force of six men was applied for two and a half 
hours. The patient being under the influence of chloroform and ether, 
aided by yourself, Drs. Fries, Cary, Graham, and Kauffman, I com- 
menced by manipulations, adducting, rotating, abducting, and elevat- 
ing the arm. These efforts had been made for about ten minutes, and 
the least possible violence employed, when a tumefaction appeared in 
the pectoral region, which in a few minutes attained a considerable 
size. Supposing that the axillary artery was ruptured, as no pulse 
could be felt at the wrist, a ligature was immediately applied to the 

1 Dieffenbach, Bost. Med. and Surg. Journ., vol. xxii, p. 382, from Medicin. 
Zeitunsr. 



598 DISLOCATIONS OF THE SHOULDER. 

vessel at the upper part of its course. The operation was performed 
about 10 o'clock a.m., and compression of the pectoral region made by 
means of a sponge and broad roller. On removing this the next 
morning, the tumefaction had nearly disappeared. The patient con- 
tinued comfortable, and about nine days after the application of the 
ligature I was compelled to leave the city on a professional visit to 
Indiana. I left on Friday afternoon and returned on Monday morn- 
ing, at which time I learned that my patient had died on Sunday 
morning, from haemorrhage at the seat of ligature." 

The following is a resume of similar accidents which have from time 
to time occurred in the practice of other surgeons. 

Rupture of the Axillary Artery. — Desault twice observed, after at- 
tempts to reduce old luxations of the shoulder, " tumeurs aeriennesP 
It is quite probable, however, that in each case the tumor was caused 
by the rupture of a bloodvessel, and probably an artery. 1 

Pelletan, also, attempting to reduce a luxation of four months' stand- 
ing, thought he produced a tumeur aerienne, but it being opened the 
patient bled to death. 2 

Malgaigne, attempting to reduce a dislocation of sixty-eight days' 
standing, was surprised by a sudden tumefaction in the axilla, and on 
the shoulder, which caused so much alarm as to induce him to discon- 
tinue his eiforts. Ice was applied, and the haemorrhage, which he 
thought came from muscular branches, was arrested. 3 Verduc saw 
the axillary artery ruptured in the same manner, in consequence of 
which the patient died. 4 J. L. Petit, Dupuytren, Delpech, and Nel- 
aton, met with similar cases. C. Bell reports an example of rupture 
of the artery with extensive laceration of the muscles, and which de- 
manded immediate amputation. Delpech ruptured the artery, and his 
patient died immediately. 5 Flaubert was more fortunate, the effused 
blood being absorbed after a few days. 6 John C. Warren, of Boston, 
tied the subclavian artery to arrest the progress of an enormous aneu- 
rismal tumor in the axilla, caused by the reduction of a recent disloca- 
tion. 7 Gibson, of Philadelphia, lost two patients from rupture of the 
artery in attempting to reduce old luxations of the humerus, 8 and he 
relates another fatal case occurring in the practice of David, of Rouen. 
Leudet, of Rouen, lost a patient in this way in 1824. In this latter 
case, and in both the cases occurring in the practice of Gibson, there 
was a fracture, also, of the lower margin of the glenoid cavity. Cal- 
lender ruptured the artery in an attempt to reduce a dislocation at six 
weeks. 9 Mr. Lister lately met with the same accident. 10 

In addition to these lesions of arteries and veins caused by attempts 

1 Desault, Journ. de Chir., t. iv, p. 301. 

2 Pelletan, Chir. Clin., t. ii, p. 951. 3 Malgaigne, op. cit., p 150. 

4 Verduc.OpeVat. de la Chir., 1693, t. i, p. 559. 

5 Malgaigne, op cit., p. 152. 

6 Memoires sur plusieurs cas de Luxationes, etc. Repertoire d'Anat. et de Phys., 
1827, Obs. 3. Four cases of injury to the Axillary or Brachial Vessels or Nerves. 

7 Warren, Amer. Journ. Med. Sci., vol. xi, N. S , 1846. 

8 Gibson, Elements of Surg., vol. i, p. 824, 4th ed. 

9 St Barthol Hosp. Rep./l866, vol ii, p. 96. 
10 Med. Times and Gmz., Feb. 1, 1873. 



DISLOCATION OF THE HUMERUS DOWNWARDS. 599 

at reduction of dislocated shoulders, in both recent and ancient cases, 
there are several examples recorded of sudden death when no such 
lesions were disclosed in the autopsy. In the case reported by Lisfranc 
death was ascribed to cerebral congestion. MM. Lenoir and Larrey 
refer to cases, also, of lesions of the brachial plexus, causing paralysis, 
yet these were recent cases, and the reduction was easily accomplished. 1 

Rupture of the Axillary Vein. — Froriep attempted the reduction of 
the shoulder in a woman, get. 36, the dislocation having existed twenty 
days. The axillary vein was torn entirely across, and death ensued in 
an hour and a half. 2 

Professor D. H. Agnew, of the University of Pennsylvania, rup- 
tured the axillary vein while attempting to reduce a dislocation of six 
weeks. The woman, set. 60, had a subcoracoid dislocation, and while 
the arm was lifted and extension made according to La Mothers method, 
the vein was ruptured, causing a very large tumor covering the entire 
breast. Compresses and bandages were at once applied and continued 
for several weeks, the case resulting in a complete cure, but with the 
bone unreduced. 3 

Rupture of Artery and Vein. — Platner mentions a case of rupture 
of both artery and vein, in which death ensued from subsequent rup- 
ture of the sac. 

Charles Bell reports a case in which the artery was ruptured, at the 
New Castle Infirmary, and the parts adjacent so much injured that 
immediate amputation became necessary. It seems quite probable 
therefore that the vein was also torn, but this is not stated. 4 

Injury to Axillary Nerves. — Very many accidents of this kind have 
happened from time to time, some of which have been reported by 
Flaubert, Malgaigne, Lenoir, Larrey, and others. 

Avulsion of the Arm. — Guerin tore the arm completely from the 
body, in an attempt to reduce a dislocation of three months' standing, 
in a woman 63 years of age. 5 

Inflammation, etc. — Mr. Hutchinson, of London, reported in 1866 
that inflammation, suppuration, and death had resulted from an at- 
tempt made to reduce an old dislocation of the humerus, under his own 
observation. 6 

Fracture of the Humerus. — In the following case an attempt to re- 
duce an ancient dislocation of the humerus occasioned a fracture of the 
surgical neck. 

Martha Hogan, set. 70, of Brooklyn, N. Y., was admitted into the 
Long Island College Hospital during the spring of 1860. The dislo- 
cation had existed six weeks, and was subcoracoid. On the day of 
admission an attempt was made to reduce it, both by Dr. Johnson and 
myself, without an anaesthetic, in which we both failed. I then gave 

1 Lisfranc, Lenoir. Larrey, Bui. de la Soc. Chir., i, i. 

2 Veraltete, Luxationem, etc. "Weimar, 1834, p. 85. 

3 Philadelphia Med. Times, Aug. 16, 1873. 

4 See De Forest Willard's excellent summary of these and other cases in Phila.. 
Med. Times, Aug. 16, 1873. 

5 IS. Cooper's First Lines, vol. ii, p. 466. Amer. Journ. Med. Sci., 1828, p. 136. 

6 Lond. Hosp. Keports, vol. ii. (See Cincinnati Journ. Med., Aug. 1866, p. 361.) 



600 DISLOCATIONS OF THE SHOULDER. 

her ether, and now discovered that she had a fracture of the second 
and third ribs on the same side. The fractures were ununited. While 
manipulating, pulling the arm gently and rotating, the surgical neck 
of the humerus gave way. She did not survive the injury many days, 
and the autopsy confirmed this diagnosis. 

In December, 1874, Dr. Stephen Smith, of Bellevue, met with the 
same accident in attempting to reduce a subglenoid dislocation of eight 
weeks' standing, before the class of medical students. The patient, a 
man aged about 40, was under the influence of ether.- Manipulation 
and extension had been freely employed in various directions, but the 
fracture took place when, at my suggestion, extension was for a mo- 
ment relinquished, and while Dr. Smith was rotating the humerus 
with the elbow at a right angle with the body. 

In December, 1865, Rosanna Casey, set. 32, was admitted to Bellevue 
with a subcoracoid dislocation of the left shoulder. The accident oc- 
curred six weeks before. On admission, one of the house surgeons 
attempted reduction, and, as I am informed, fractured the surgical 
neck of the humerus. After which, Dec. 9th, 1 attempted reduction 
before the class, the patient being under the influence of ether, but 
without success. 

Summary of Accidents. — Rupture of an artery, nineteen cases ; most 
of which were known to be ruptures of the axillary artery. Callender, 
Lister, and Blackman tied the axillary, and the patients all died. 
The subclavian was tied by Warren successfully. Gibson also tied the 
subclavian, but his patient died. Nelaton did the same, and the result 
is not stated. 

Rupture of vein alone, two cases. Froriep's patient died ; Agnew's 
patient was saved. 

Rupture of artery and vein, probably two cases. Platner's patient 
died. In Bell's case the result is not stated, except that amputation 
was practiced. 

Avulsion of arm, one case. Patient died. 

Of the whole number, twenty-four, fifteen terminated fatally, three 
are uncertain, and six recovered. 

Of fractures of the neck of the humerus I have reported three cases. 
In neither of these was the reduction accomplished. My own patient 
died, but probably not in consequence of any injury suffered in the 
attempt at reduction. 

Norris has reported three cases of ancient dislocation 'into the axilla, 
treated at the Pennsylvania Hospital ; one, of four weeks' standing, 
was reduced in thirty seconds by the aid of pulleys; the second, which 
had existed seven weeks, was reduced by the same means in about one 
hour; and the third, dislocated ten weeks, was left unreduced after 
extension and counter-extension had been made for an hour. In the 
second case, however, suppuration occurred in or about the joint, and, 
on the tenth day, the abscess was opened, giving exit to a large amount 
of pus. He left the hospital with the parts about the shoulder still 
much hardened and stiff. 1 

1 Norris, Amer. Journ. Med. Sci., xxxi, p. 24. 



DISLOCATION WITH FRACTURE. 601 



Dislocation, with Fracture of the Humerus near its Upper End. 

We have thus far omitted to speak of the treatment of dislocations 
of the humerus accompanied with fracture near its upper end. The 
older writers, almost without an exception, agree in declaring the re- 
duction of these dislocations impossible, until the fracture had united. 
And, so late as the year 1828, we have the* report of a case treated in 
this manner by a surgeon in Massachusetts. Dr. Warren, of Boston, 
himself reduced the dislocation at the end of four weeks, when the 
fracture was found to have united. 1 

But since the introduction of anaesthetics immediate attempts at 
reduction have more often proved successful ; and in no case can the 
surgeon excuse himself for having omitted to make the effort. 

Richet reports an example of this kind in a man sixty-eight years 
of age, in whom the dislocation was complicated with a fracture of the 
neck of the humerus. The attempt was not made until the fourth 
day, when it proved successful without extension. The fracture was 
afterwards adjusted and consolidated, so that he recovered the complete 
use of his arm. 2 

At a meeting of the New York Academy of Medicine, in May, 
1855, Dr. Watson reported a case of fracture of the humerus near its 
head, complicated with a dislocation into the axilla. The patient was 
a robust man, passed the middle age, and had received the injury by 
a blow on the shoulder from a steam-engine. He was very much pros- 
trated at the time of being admitted into the hospital, and the exami- 
nation was not made until the following morning. The arm was then 
found lying close to the side, but in other respects it presented the 
usual signs of a dislocation. Ether was immediately administered; 
and while extension and counter-extension were applied, and a sweep- 
ing motion given to the arm, drawing it from the body, firm pressure 
with the fingers was made in the axilla, forcing the head toward the 
socket, and the bone slipped into its position. 3 

In the Transactions of the American Medical Association, I have re- 
ported a case of supposed dislocation, accompanied with a fracture, 
which I succeeded in reducing on the eighth day. 4 

I have, however, twice failed in attempts to reduce similar disloca- 
tions. The first patient, John Riley, set. 49, was admitted to Bellevue 
Hospital, March 29th, 1864, having received the injury two days 
before. The dislocation was subcoracoid, and the humerus was broken 
at its surgical neck. Having placed him under the influence of ether, 
assisted by Dr. Stephen Smith and several other surgeons of the hos- 
pital, I attempted to reduce the dislocated bone, but after a trial, pro- 
longed through one hour or more, the effort was abandoned. 

The second case was in a man aged about 40 years, who was admitted 

1 Boston Med. and Surg. Journ., No. 1, 1828; also, Amer. Journ. Med. Sci., 
vol. ii, p. 233. 

* Richet, Amer. Journ. Med. Sci., vol. xii, new ser., p. 293, from Bulletin do 
Therap. 

3 Watson, Amer. Journ. Med. Sci., vol. xvi, new ser., p. 383. 

4 Op. cit., vol. ix, p. 93. 

39 



602 DISLOCATIONS OF THE SHOULDER. 

to Bellevue Hospital in July, 1864, with a dislocation of the head of 
the humerus forwards, and a fracture of the surgical neck, of four weeks' 
standing. A surgeon had attempted reduction immediately after the 
receipt of the injury, but had failed. We found the fracture still un- 
united, and placing him under the influence of ether, we tried faith- 
fully, by pushing and pulling, and by various other manoeuvres, to 
reduce the dislocation, but without success. 

The fractures united in both cases promptly, and attempts were sub- 
sequently made to reduce the dislocation, but to no purpose. 

In neither of the three cases of fracture of the surgical neck of the 
humerus, reported in the preceding pages as having been caused by 
efforts to reduce dislocations, were the dislocations subsequently re- 
duced. 

Examples have been recorded by surgeons in which the reduction 
has been accomplished immediately, and without much difficulty, by 
simple pressure upon the head of the bone, while the patient was under 
the influence of an anaesthetic, and without the aid of extension ; in- 
deed, it is quite doubtful whether extension in these cases is of any 
service. If, however, the surgeon were to fail by pressure alone, it 
would be proper to employ extension and manipulation. 1 In the event 
of a failure by these means, the case ought to be treated as a fracture, 
and the earliest period after the union of the fragments should be 
seized upon to accomplish the reduction of the dislocation. The occa- 
sional success of the older surgeons by this method is sufficient to 
warrant the attempt. 

The treatment of compound dislocations of this joint will be dis- 
cussed in a separate chapter devoted to the general consideration of 
compound dislocations of all the joints connected with the long bones. 

I 2. Dislocation of the Humerus Forwards. (Subcoracoid and 
Subclavicular.) 

Causes. — The causes of this dislocation are the same with those 
which produce dislocation downwards into the axilla, except that it is 
more likely to occur in a fall upon the elbow or upon the hand when 
the line of the axis of the arm and forearm is thrown behind the body. 
If it is the result of a direct blow, the impulse has usually been re- 
ceived rather upon the back than upon the outer side of the head of 
the humerus ; or the upper end of the bone having been originally 
thrown directly downwards upon the inferior edge of the scapula, may 
have been made to assume the position forwards, beneath the pectoral 
muscle, in consequence of the peculiar action of the muscles, or of the 
position of the arm in an attempt to rise. By this latter mode of 
explanation the dislocation forwards is consecutive only upon a dislo- 
cation downwards. 

In several instances which have come under my notice the disloca- 
tion has been due to muscular action alone. In one example the dis- 

1 Hartshorne, Case reduced by Manipulation, Amer. Journ. Med. Sci., Jan. 1855, 
pp. 273-4, from Med Examiner. 



DISLOCATION OF THE HUMERUS FORWARDS. 603 

location occurred frequently in consequence of epileptic convulsions. 
This was in the person of a lad, net. 18, of a slender frame and feeble 
muscles. When the dislocation had taken place, he was frequently 
able to reduce it himself; sometimes he was obliged to call upon a sur- 
geon, and at other times he left it out a day or two, or until it became 
reduced spontaneously. This spontaneous reduction generally took 
place at night, during sleep. At the time he called upon me the bone 
had been out two days, and he could not reduce it. I administered 
chloroform, and then made repeated and prolonged efforts at reduc- 
tion, adopting all the usual modes of manipulation, but without resort- 
ing to mechanical appliances. The father now refused to allow me to 
proceed, and he w r as taken home with the bone unreduced. The fol- 
lowing day he called at my office, to say that during the night, w r hile 
asleep, and, he thinks, while turning over in bed, the bone suddenly 
resumed its place. 

Dr. Edward L. Pardee, of this city has recently met with a case of 
simultaneous dislocation of both shoulders, in a man set. 38, caused by 
a fall from a carriage, his arms being extended in front of him, and 
the force of the concussion being received upon his hands. Both of the 
dislocations were subcoracoid ; and, aided by Dr. Glover C. Arnold, 
they were easily reduced. 

Surgical writers occasionally refer to similar examples, but the 
number of cases of double dislocation on record is small. Most of those 
recorded have happened when the arms were extended in front of the 
body, as in Dr. Pardee's case just cited; and the dislocations were gen- 
erally subcoracoid. 

Pathology. — Omitting for the present to speak of partial luxations, 
the existence of which, as a form of traumatic dislocation, we are pre- 
pared to question, we shall proceed at once to describe the anatomical 
relations and the various lesions which generally accompany a complete 
luxation forwards. 

Of these we shall observe two principal varieties, differing mainly in 
the degree or extent of the displacement. 

Thus we may find the head of the humerus resting beneath the cora- 
coid process, having the conjoined tendon of the short head of the biceps 
and of the coraco-brachialis lying upon its anterior surface, while its 
posterior and outer surface rests upon the venter of the scapula in front 
of the glenoid fossa ; in which position it has usually thrust up, to a 
greater or less extent, the belly of the subscapular muscle. 

Sir Astley Cooper, Fergusson, and others, when mentioning this form 
of dislocation, call it a "dislocation into the axilla;" by Boyer it is 
called a "primary luxation forwards." Dr. Wood, of New York, has 
reported an example, accompanied with a fracture of the neck of the 
humerus, which he has named "dislocation under the subscapulars 
muscle." The drawing which accompanied the report, made from the 
autopsy, sufficiently shows that it was a dislocation of the same charac- 
ter as that which w r e are now describing. 1 Dr. Parker has called at- 
tention to a similar case, an account of which was first given in Reese's 

1 Wood, New York Journ. of Med., May, 1850, p. 282. 



604 



DISLOCATIONS OF THE SHOULDER. 



edition of Cooper's Surgical Dictionary. The head of the humerus 
reposed in the " subscapular fossa." 1 By Malgaigne, Vidal (de Cassis), 
and others, this is called a subcoracoid dislocation, a term which, as 



Fig. 268. 



Fig. 269. 





Subcoracoid dislocation. 



Subclavicular dislocation. 



being more distinctive and appropriate than either of the others, I shall 
choose to adopt. 

In the second variety, the head, having escaped from underneath the 
coracoid process, is made to approach nearer to the sternum, so as to 
apply itself more or less closely to the inferior edge of the clavicle. 
In which case the head and neck will be placed behind the pectoralis 
minor, and also behind the short head of the biceps and coraco-brachi- 
alis; or between these several muscles on the one hand, and the serra- 
tus magnus, covering the second and third ribs, on the other hand. 

Upon the appearances which accompany this more advanced form of 
dislocation writers have generally based their descriptions, diagnosis, 
treatment, etc., of forward luxations. 

In either form of the accident, the deltoid, with, the supra- and infra- 
spinatus, is greatly stretched, and the two latter sometimes torn; the 
subscapularis is displaced upwards and backwards, while its tendon is 
in some instances completely wrenched from the head of the humerus. 
Mr. Erichsen has seen the lesser tubercle itself completely broken off 
in two examples of this accident which he has been permitted to ex- 
amine after death. 2 Occasionally the axillary nerves are carried for- 
wards with the head of the bone ; and in this case the pain produced 
by their being thus pressed upon is even greater than in dislocations 
into the axilla. 

In this accident, as in dislocation downwards, the long head of the 
biceps is sometimes broken ; the circumflex nerve may be contused or 
ruptured, and the capsule is generally torn very extensively. 



i Parker, New York Journ. of Med., March, 1852, p. 187. 
2 Erichsen, Science and Art of Surgery, 2d Amer. ed., p. 250. 



DISLOCATION OF THE HUMERUS FORWARDS. 



605 



Symptoms. — If the dislocation is subclavicular (Fig. 269), a depres- 
sion exists under the outer end of the acromion process, extending also 
underneath its posterior margin ; the elbow hangs away from the body, 
and a little backwards ; the axis of the limb is much changed, being 
thrown inwards in the direction of the middle of the clavicle, the whole 
body inclining moderately to the same side ; there is also more or less 
inability to move the arm, especially in a direction forwards or out- 
wards ; a fulness is seen underneath the clavicle, and to the sternal side 
of the coracoid process, occasioned by the head of the humerus, the 
head moving with the shaft. To these we may add the common sign 
of all dislocations of the humerus, mentioned by Dugas, viz., the im- 
possibility of placing the hand upon the opposite shoulder while at the 
same moment the elbow is made to touch the front of the chest. 

If the dislocation is forwards, but subcoracoid, the head of the bone 
will be found below this process and deep in the anterior margin of the 
axillary fossa. It cannot, therefore, be so distinctly felt ; but the other 
signs are the same as in the dislocation forwards under the clavicle. 

Prognosis. — While on the one hand experience has shown that the 
axillary nerves and artery are less liable to suffer serious and perma- 
nent injury than in dislocation dowmvards, and that the capsule, with 
the tendinous and muscular tissues about the joint, are no more liable 



Fig. 270. 




Subcoracoid dislocation. 



to laceration — on the other hand, the difficulty of reduction has been 
often increased, and consequently a large number of examples, in pro- 
portion to the actual number which occur, have been left unreduced. 

Dr. Norris relates a case which the surgeon who was first called sup- 
posed to be a mere contusion, but which, on being admitted to the 



606 DISLOCATIONS OF THE SHOULDER. 

Pennsylvania Hospital, three months after the accident, was found to 
be a dislocation forwards under the clavicle. The arm was almost 
useless. Dr. Norris made extension and counter-extension with com- 
pound pulleys nearly an hour, but to no purpose ; and finally, at the 
request of the patient, the attempt was given over. 1 

Treatment. — The same rules of treatment which we have established 
in relation to dislocations into the axilla will be found to be applicable 
to this dislocation, with the exception that the extension will have to 
be made generally at first somewhat in a line backwards from the body, 
and that our efforts will frequently have to be continued with more 
perseverance, although with less fear of injury, in consequence of sup- 
posed adhesions between the artery and the adjacent tissues. The ex- 
tension also must always be made downwards and outwards, if the dis- 
location is subclavicular, until the head of the bone has escaped from 
beneath the coracoid process ; we may then pull directly outwards or 
even upwards, while at the same moment pressure is made with the 
hand upon the head of the bone in the direction of the socket, and the 
arm is rotated inwards. 

If the dislocation is subcoracoid, our modes of procedure need 
scarcely vary in any respect from those which we have recommended 
for dislocations into the axilla. 

The plan adopted in the following case has been found sufficient in 
several examples of subcoracoid dislocation. 

Mr. McA., of Buffalo, set. 73, moderately muscular, fell through a 
trap-door, striking upon his right elbow, and dislocating the humerus 
forwards. Within two hours after the accident, I found the head of 
the bone resting under the coracoid process, where it could be distinctly 
felt and seen. There was a marked depression under the acromion 
process, and the arm was carried out from the body and slightly back. 
He had not suffered much pain. The patient was seated in a chair, 
and while Dr. Lemon, who was at that time my pupil, supported the 
acromion process, I pushed the head of the humerus outwards toward 
the socket with my left hand, while with my right I pulled gently 
upon the arm in the direction of the axis of the body. After about 
twenty seconds it slid suddenly into its place with an audible snap. 

Simple manipulation alone will also be found sufficient in many 
cases of subclavicular dislocation. 

A German, Simeon Grennas, set. 21, fell upon an icy sidewalk, and 
dislocated his right humerus under the clavicle. We found him about 
an hour after the accident sitting with his head inclined to his right 
side, and supporting his elbow with his left hand. A marked depres- 
sion existed under the outer end of the acromion process, and instead 
of the usual fulness there was a flatness under the process behind. The 
elbow was carried out from the body, and very slightly backwards. 
While Dr. Boardman supported the acromion process I lifted the 
elbow from the side, carrying it first upwards and backwards, and then 
forwards, making thus a short detour with the arm, and when the 
manoeuvre was nearly completed the bone slid into its socket with a 

1 Norris, Amer. Journ. Med. Sci., vol. xxv, p. 279. 



DISLOCATION OF THE HUMERUS FORWARDS. 607 

slight snap. No extension was used, and no more force was employed 
than was sufficient to lift and rotate the arm. He was not at the time 
of the reduction faint nor were his muscles relaxed from any other cause. 

More than once I have accomplished the reduction by extension 
made directly upwards, as in the following example. 

A gentleman, forty -five years of age, had his left shoulder dislocated 
forwards under the clavicle in a railroad collision, on the 8th of Octo- 
ber, 1858. A young surgeon had been making extension in various 
ways for half an hour, when, by placing my foot upon the top of the 
scapula and drawing the arm directly upwards, 1 accomplished the 
reduction immediately and without much effort. Six months after the 
accident, I found the deltoid muscle considerably wasted, and he was 
still unable to raise his arm to a right angle with the body. 

I have in this way also reduced a dislocation which had existed 
seventeen days, the nature of the accident having been misunderstood 
by the attending surgeon. The man was twenty-three years old, and 
quite muscular. The dislocation had been produced by a severe blow 
received directly upon the shoulder, and the arm was still considerably 
swollen and very tender. The reduction was accomplished in a few 
seconds while the patient was under the influence of chloroform, but 
by my hands alone, aided only by the pressure of the foot upon the top 
of the scapula. The method adopted successfully in both of the pre- 
ceding cases, namely, pulling directly upwards, ought generally to be 
considered a last resort, inasmuch as it especially exposes the axillary 
artery, vein, and nerves to injury. 

In December, 1857, Dr. White, of Buffalo, and myself, reduced a 
subclavicular dislocation of the right shoulder, which had existed sixty 
days, in a man sixty-eight years of age. The surgeon who first saw 
the man thought it was only a sprain or a severe bruise. When he 
came to Buffalo, the whole limb was enormously swollen, and neither 
Dr. White nor myself had much expectation of accomplishing a re- 
duction without a resort to pulleys and anaesthetics. He was, however, 
placed upon the floor, and after extension made for about half an hour, 
during which time we had pulled the arm in various directions, up- 
wards, outwards, and downwards, I at last succeeded while my heel 
was placed in the axilla, and while the limb was undergoing a slight 
rotation. No anaesthetic was employed. 

Dr. M. C. Cuykendall, of Bucyrus, Ohio, informs me that he has 
recently reduced a subclavicular dislocation on the sixty-fourth day, in 
a man 62 years old, by the following method : " As a last resort I 
secured the pulleys to the arm above the elbow, making the counter- 
extension with Skey's knob in the axilla, flexed the arm and made ex- 
tension downwards and forwards ; and when w r ell extended I moved 
his body under the pulley ropes, so as to bring the arm forcibly across 
the breast; then, keeping up the extension, I had Dr. Richey place 
his knee upon the top of the scapula, and lock his fingers around the 
elbow, w 7 hile I placed my knee against the elbow and locked my 
fingers around the top of the scapula, and directing the extension re- 
moved, we forced the bone upwards and outwards to its socket ;" ad- 
hesions were felt to give way, and the restoration of the bone was 
found to be complete. 



608 DISLOCATIONS OF THE SHOULDER. 

It will be understood that this method did not succeed until after 
repeated and long-continued efforts had been made by other methods, 
such as pulling down, pulling out, and pulling directly up. Dr. Cuy- 
kendall informs me that this is the second time he has succeeded in 
"completing" the reduction of old dislocations of the shoulder by this 
manoeuvre. 

These several cases are mentioned that the surgeon may understand 
how impossible it is always to establish absolute and invariable rules 
of procedure which shall be applicable to every accident of this char- 
acter. The method which will succeed readily in one case may fail 
completely in another, although belonging to the same class, and not 
apparently differing in its anatomical relations. Before relinquishing 
the attempt, we ought to have put into requisition all the expedients 
which the experience of other surgeons has shown to be worthy of a trial. 

During the year 1865, two ancient subcoracoid dislocations came 
under my observation at Bellevue Hospital. One of these cases, in 
the person of James Thompson, set. 49, had existed two years or more. 
He was employed about the hospital as a carpenter, and has a tolera- 
bly useful arm. The second, in the person of Rosanna Casey, aet. 32, 
had existed six weeks when she was admitted. Various attempts had 
been made to reduce the dislocation before admission. During the 
week following her admission, an attempt was made at reduction by 
Dr. Verona, an intelligent house surgeon, subsequently by Dr. James 
R. Wood, and at the end of three months the attempt was made by 
myself, before the class of medical students, the patient being each 
time under the influence of an anaesthetic. She was finally discharged 
with the bone still unreduced. 

Mary Coffee, aet. 46, was admitted also to the Charity Hospital, in 
Feb. 1864, with the same dislocation, which had existed six months, 
having been mistaken at first for a fracture. I found her arm free 
from swelling or paralysis, and moving quite freely in its new socket, 
and declined. to make any attempt at reduction. 

July 28, 1873, an Irishman, about 40 years of age, was admitted to 
St. Francis's Hospital with a subcoracoid dislocation of the humerus of 
eight or nine weeks 7 standing. The surgeon who first saw him believed 
that he reduced the dislocation, but several weeks later he found it was 
again out of place, and he tried ineffectually to reduce it. My own 
efforts, continued for an hour or more, were equally unsuccessful. 

The two following cases are recorded in order that they may illus- 
trate the apparent inutility of a successful reduction in some cases. 

William E. Disbrow, of Bridgeport, Conn., received a subcoracoid 
dislocation of the right arm, in consequence of a violent and direct 
blow, May 9th, 1870. Dr. George Lewis, of Bridgeport, a very in- 
telligent surgeon, reduced the dislocation within half an hour, the 
patient being under the influence of ether. The restoration of the 
bone was complete, and attended with an audible sound. The arm 
was subsequently very painful, and at the end of three weeks Mr. 
Disbrow consulted a "natural bone-setter," who manipulated the 
limb violently, and perhaps dislocated it. July 9th, 1870, eight 
weeks after the original accident, I found the bone unreduced, and in 



DISLOCATION OF THE HUMERUS BACKWARDS. 609 

the presence of a number of medical gentlemen at Charity Hospital, 
effected reduction. The patient was anaesthetized, and the reduction 
was accomplished only after considerable extension and manipulation 
had been practiced ; the return of the bone to its socket being accom- 
panied with a grating sensation. A thick pad was then placed in the 
axilla, and the arm and forearm secured across the front of the chest. 
Mr. Disbrow remained under observation for some time ; but it was 
soon evident that the head of the bone was gradually receding from 
the socket, and that he was not to have a very useful limb. 

Jan. 10th, 1875, Leonard Ball, set. 40, was thrown from a carriage 
at Norwich, Conn., causing a subcoracoid dislocation of the left arm. 
Five days later Dr. Patrick Cassidy, of Norwich, reduced the disloca- 
tion, the reduction being accompanied with a grating sensation. Four 
days later Dr. Cassidy found the arm again dislocated, and he again 
reduced it. Feb. 11th, thirty-two days after the original accident, the 
arm was examined by myself and other visiting surgeons at Bellevue. 
Some of the gentleman doubted whether it might not be a fracture of 
the surgical neck of the scapula. In my opinion it was a dislocation. 
On the same day, before the class, and under ether, I effected reduc- 
tion by manipulation, very little extension being employed. The arm 
was, however, manipulated in various directions, and considerable 
adhesions were torn before success was attained, the bone returning to 
its socket suddenly, and with a grating sensation, while the heel was 
in the axilla, and I was pulling moderately upon the arm. No one 
doubted the fact of reduction ; the arm was now done up as in the 
preceding case, and the patient remanded to his ward. 

A few days later I found the head of the bone had receded from its 
socket, and was evidently tending to assume the position in which I 
first saw it ; and the motions of the joint were very limited. He was 
discharged from the hospital after two or three weeks, and I have not 
seen him since. 

It is quite probable that among the successful cases of reduction of 
old dislocations of the shoulder, reported from time to time, many 
have completed their history in a similar manner. Possibly there 
may have been in each of these examples a fracture of the inner lip of 
the glenoid cavity, a condition which has been verified in several 
autopsies of old shoulder dislocations. 

The rapid changes which often take place in the socket, and in the 
condition of the adjacent tissues, may also account for the difficulty 
which we often experience in reducing these dislocations, and of retain- 
ing them in place after reduction. In Professor Lister's case, already 
referred to, at the end of seven weeks there was a complete socket 
formed, smooth, cartilaginous, and partly bony; and strong fibrous 
bands had formed between the coracoid process, the surgical neck of 
the humerus, and the axillary artery, containing a spiculum of bone. 

\ 3. Dislocation of the Humerus Backwards. (Subspinous.) 

This form of dislocation has been seldom met with. Only two 
cases, according to Sir Astley Cooper, occurred in Guy's Hospital in 



610 DISLOCATIONS OF THE SHOULDER. 

thirty-eight years ; but in the last edition of Sir Astley Cooper's 
treatise on Fractures and Dislocations, edited by Bransby Cooper, nine 
cases are mentioned. 1 Sedillot, 2 Malgaigne, Desclaux, 3 Van Buren, 4 
W. Parker, 5 Lepelletier, 6 Trowbridge, 7 Physick, Snyder, 8 Stephen 
Smith, and myself, have each seen one example. Examples have also 
been seen by Dupnytren, Arnolt, Best, Levacher, Berard, Fizeau, Vel- 
peau, Fergusson, Kirkbride, 9 and by Rogers. 10 

Dr. Stephen Smith's case was seen by myself ten days after the ac- 
cident, by courtesy of Dr. Smith. The patient, John Creswell, set. 36, 
fell down a flight of stairs Sept. 11, 1871, striking on the front of his 
shoulder. A surgeon, who saw him a few hours after, thought it was 
simply a bruise. Sept. 21, he was an inmate of Bellevue Hospital. 
The head of the humerus could be distinctly seen in its new position, 
and there was a marked depression under the acromion process, especi- 
ally in -front. The elbow hung very slightly from the body, and 
scarcely more forwards than the opposite elbow. He could carry it 
forwards pretty freely, and a little out, but he could not carry it back. 
He suffered very little pain, and there was no swelling of the arm or 
hand. On the following day Dr. Smith reduced the dislocation easily, 
by pulling the arm forwards, and at the same time pushing upon the 
head from behind. Dr. Smith informs me, however, that the bone 
became displaced on the following day ; but that it was easily reduced, 
and afterwards remained in place. 

Causes. — One of the patients mentioned in Mr. Cooper's book had 
his shoulder dislocated backwards in an epileptic convulsion ; one had 
fallen upon his shoulder; another met with the accident while pushing 
a person violently with the arm elevated ; and a fourth, seen by Coley, 
was " pulled down by a calf which he was driving, a cord having been 
tied to one of the calf's legs, and being held fast by the man's hand." 
My own patient, Frederick Kretner, had his arm caught in machinery 
on the 14th of January, 1860. The dislocation was discovered when I 
was preparing to amputate the arm soon after the accident occurred. 
Desclaux's patient fell from a height with his arm in front of him. In 
the case seen by Dr. Parker, of New York, a woman, set. 60, had fallen 
forwards and struck upon the outside of her elbow, arm, and shoulder. 
No attempt was made to reduce it until the fourteenth day, she not 
having for some time called the attention of any surgeon to its condi- 
tion. Trowbridge's patient was thrown from a horse, striking on the 
palm of his hand. 

Pathology. — Mr. Cooper has given us a careful account of the dis- 
section in the case of Mr. Complin, already alluded to, whose arm had 

1 A. Cooper, op. oit , p. 352. 

2 Sedillot, Amer. Journ. of Med. Sci., vol. xiii, p. 551, Feb. 1834. 

3 Desclaux, New York Journ. of Med., Nov. 1851, p. 109, from Kevue Medicale. 

4 Van Buren, ibid., Nov. 1851, p. 110. 

5 Parker, ibid., March, 1852, p. 186. 

6 Lepelletier, Amer. Journ. Med. Sci , vol. xvi, p. 526, from Arch. Ge"n., Nov. 
1834. 

7 Trowbridge, Bost. Med. and Surg. Journ., vol. xxvii, p. 99. 

. 8 Gibson's Surgery. 9 New York Journ. Med., March, 1852. 

10 Amer. Med. Times, November 9. 



DISLOCATION OF THE HUMERUS BACKWARDS. 611 



been dislocated by muscular spasm. This gentleman was fifty-two 
years of age, and had been subject to epileptic fits, in one of which the 
shoulder was dislocated. Many attempts were made to reduce it, but 
although it seemed to be easily drawn into its socket by extension 
merely, yet, as soon as the force ceased, the head of the bone slipped 
again upon the dorsum scapulae, and in this situation it was finally per- 
mitted to remain until his death, which did not take place until five 
years after. In the meantime he was able to move the limb but very 
slightly, so that his arm was almost useless. 

Mr. Cooper, to whom the arm was sent after death, found the head 
of the bone resting under the spine of the scapula, and against the pos- 
terior edge of the glenoid fossa, where it had formed a slight depression, 
and the head itself had become somewhat changed in form by absorp- 
tion. The tendon of the subscapularis muscle and the internal portion 
of the capsular ligament were torn at the point where the muscle was 
inserted, but the greater portion of the capsule remained, having been 
pressed back by the head of the bone. The supraspinatus was stretched, 
while the infraspinatus and teres minor were relaxed. The long head 
of the biceps was elongated, but not ruptured. The glenoid fossa was 
rough and irregular upon its surface, the cartilage being absorbed. 

The fact that the bone would not remain in place when reduced, was 
explained by the rupture of the subscapularis, and the consequent loss 
of antagonism to the action of the infraspinatus and teres minor. 1 

The accompanying drawing is a copy of that furnished by Mr. Cooper, 
to illustrate the position occupied by the bone. 

I ought to mention that this case has been regarded by Vidal (de 
Cassis), Malgaigne, and others, as only subacromial, and as a variety 
of the dislocation backwards, differing from that in which the head 
of the bone occupies a position under- 
neath the spine. But as I can see no dif- 
ference except in the degree or extent 
of the displacement, I prefer not to re- 
gard the distinction made by these sur- 
geons. 

Symptoms. — The signs of this accident 
are, a projection under the spine of the 
scapula, produced by the head of the 
bone, the head being obedient to the 
motions of the arm; a corresponding de- 
pression in front and under the outer ex- 
tremity of the acromion process; a wide 
space between the head of the bone and 
the coracoid process, into which the 
fingers may be pushed deeply ; the axis 
of the shaft of the humerus directed up- 
wards and outwards toward a point pos- 
terior to the glenoid fossa. The forearm is usually carried forwards 
across the chest, and the humerus rotated inwards, unless the subscapu- 



FlG. 271. 




Subspinous dislocation. 



Sir Astley Cooper, op. cit., p. 354. 






612 DISLOCATIONS OF THE SHOULDER. 



laris muscle is torn. Immobility exists, but the motions of the arm 
are not generally so much impaired as in either of the other disloca- 
tions; and finally, as in all other dislocations of the humerus, the hand 
cannot be laid upon the opposite shoulder while the elbow touches the 
front or side of the chest. In Parker's case the elbow was thrown 
outwards, although the arm was carried very much across the chest. 
In Smith's case the arm was nearly vertical. Desclaux's patient held 
his hand upon his head, with his arm horizontally across his body. 

Usually the diagnosis will be easily made ; in my own and Smith's 
case the position of the head of the bone was easily recognized, but Sir 
Astley relates one case in which, on the morning following the acci- 
dent, a surgeon was unable to discover the dislocation, and on the 
seventeenth day Bransby Cooper failed to make the diagnosis ; nor, 
indeed, on the twenty-third day did Sir Astley himself determine that 
it was a dislocation, until he had unexpectedly reduced it while manipu- 
lating upon the arm. In a second example, Sir Astley at first believed 
it to be a fracture, but a more careful examination showed it to be a 
dislocation backwards. In this instance the limb could not be rotated 
outwards, as the subscapularis was not torn, and continued to offer re- 
sistance when the arm was moved in this direction ; he was also suffer- 
ing much more pain than did the other patients, owing, as Sir Astley 
thinks, to pressure upon the articular nerves. In the case of Mr. Col- 
linson, also mentioned by Mr. Cooper, a surgeon, who saw the patient 
immediately after the accident, failed to discover the true nature of the 
injury; and Trowbridge's patient had suffered a dislocation several 
weeks before the nature of the accident was fully determined. 

Prognosis. — The reduction has always been sooner or later accom- 
plished, except in one instance ; in this case we have seen that the arm 
never recovered any considerable degree of usefulness. Mr. Collinson's 
arm, reduced on the second day, was restored to all of its functions 
within one month. Dr. Parker's patient had nearly recovered the com- 
plete use of her arm at the end of four weeks, although it was not re- 
duced until it had been out fourteen days. Sedillot succeeded in reduc- 
ing the dislocation in the case of his patient, at the end of one year and 
fifteen days. Lepelletier, after forty-five days. Trowbridge, after 
forty days ; and in this latter case we are informed that the arm was 
restored to usefulness. 

Treatment. — In the first case mentioned by Sir Astley Cooper, " the 
bandages were applied in the same manner as if the head of the hu- 
merus had been in the axilla, and the extension was made in the same 
direction as in that accident" (downwards and a little outwards). In 
less than five minutes the bone slipped into its socket with a loud snap. 
The second case was treated successfully in the same way. Mr. Dunn 
also having failed to reduce by pulling upwards, finally succeeded by 
pulling at the wrist downwards and forwards, while an assistant pushed 
the head of the bone toward the socket; the heel was not placed in the 
axilla, which Mr. Bransby Cooper thinks would have only retarded 
the reduction. Smith succeeded by a similar manoeuvre. Mr. Key 
also failed to accomplish reduction while carrying the arm upwards 
and backwards, but when the patient had become faint, by placing the 



PARTIAL DISLOCATIONS OF THE HUMERUS. 613 

heel in the axilla and pulling downwards a minute or two, the bone 
was reduced. Vidal (de Cassis) recommends the same plan, namely, 
that we shall pull in the direction in which we find the limb; Trow- 
bridge employed the pulleys successfully, the extension being made 
downwards and forwards; while Dr. Parker succeeded equally well 
with his patient, by " pulling the arm outwards, downwards, and 
slightly forwards." Counter-extension was at the same time made by 
a sheet in the axilla, and the head of the humerus was pushed toward 
the socket by the hand. In Mr. Collinson's case, the. scapula was 
supported by a towel, while " gradual extension of the limb was made 
directly outwards, and then the arm being moved slowly forwards, 
the head of the bone was distinctly heard to snap into its socket." 
The time occupied was not more than two or three minutes. Rogers 
succeeded by N. R. Smith's method. Sir Astley, however, seems to 
give the preference to the method which succeeded so happily in the 
case of Mr. G., while he was still manipulating with a view to determine 
the character of the accident. " I readily reduced the bone," he re- 
marks, "by raising the hand and arm, and by turning the hand back- 
wards behind the head." In one other instance, having failed to re- 
duce it by slight extension outwards, he raised the arm perpendicularly, 
at the same time forced it backwards behind the patient's head, and 
the reduction was promptly effected. In the case of Kretner, I first 
attempted reduction by pressure directly upon the head of the humerus; 
but failing, I proceeded to pull the arm with moderate force outwards 
and downwards, which procedure was attended with immediate success. 
The patient was under the influence of chloroform. 

After the reduction, a compress should be placed against the head 
of the bone, and underneath the spine of the scapula, and this should 
be secured in its place by several turns of a roller. The forearm ought 
also to be placed in a sling, with the elbow thrown a little back of the 
centre of the body, so as to direct the head of the humerus forwards. 



I 4. Partial Dislocations of the Humerus. 

Sir Astley Cooper has related in his treatise tw r o cases of supposed 
incomplete luxation of the head of the humerus forwards; and in con- 
firmation of his views he has added an account of the appearances pre- 
sented on dissection in the body of a subject brought into the rooms of 
St. Thomas's Hospital. Bransby Cooper, in his edition of the same 
work, furnishes the report of a similar case which came under the ob- 
servation of Mr. Douglass, of Glasgow. Hargrave and Dupuytren have 
each reported one example of this species of dislocation, in which its 
existence was said to be confirmed by dissection. 

Petit, Duverney, Chopart, Sedillot, Miller, Gibson, Malgaigne, and 
many others, have admitted its possibility ; Malgaigne, how r ever, only 
admits its existence when the capsule remains entire. 

Without intending to discuss very much at length the value of these 
opinions, I shall content myself with declaring that the existence of 
this or of any other form of partial luxation of the shoulder-joint, as a 



614 DISLOCATIONS OF THE SHOULDER. 

traumatic accident, has not up to this moment been fairly established ; 
and that the anatomical structure of the joint renders its occurrence 
exceedingly improbable, if not absolutely impossible. 

The only example mentioned by Sir Astley Cooper, in which a dis- 
section was made, showed that the long head of the biceps had been 
ruptured, and that the capsule was torn, while the head of the humerus 
was resting under the coracoid process. We shall have no difficulty, 
therefore, in assigning it to its proper place as a complete subcoracoid 
dislocation. In Mr. Hargrave's case, also, the tendon of the biceps 
was torn; while Dupuytren omits to mention what was the actual fact 
in relation to this tendon in the case seen by him, but it is distinctly 
stated that the head of the bone rested upon the ribs. Mr. Hargrave 
seems, therefore, to have described a case of rupture of the long head 
of the biceps, and it is probable that Dupuytren, who knew nothing of 
the previous history of the subject, has given us a faithful account of a 
pathological dislocation, a result of disease, and not of a direct injury. 

If the head of the humerus is driven from its socket by violence, 
and remains thus displaced, it is, we assume, a complete luxation ; 
since it is only by having placed the semi-diameter of the head of the 
bone outside of the margin of the glenoid fossa that it can be made for 
one moment to retain its abnormal position. To accomplish this amount 
of displacement upwards, or upwards and forwards, or directly forwards, 
the acromion or the coracoid process must be broken; while its occur- 
rence in any other direction must involve at least a most extraordinary 
extension, if not an actual laceration, of the capsule. If we admit, with 
Malgaigne, that occasionally the capsule has been found capable of such 
extraordinary extension without actual rupture, we still are unwilling 
to regard this as a fair example of a partial dislocation, since the head 
of the bone no longer moves in its socket, being at no point in actual 
contact with the articular surface of the glenoid fossa. It is essentially 
a complete dislocation, according to all the admitted definitions of this 
term. 

It is quite probable that a majority of these accidents were examples 
of rupture or of displacement of the tendon of the long head of the 
biceps, the effect of which, as Mr. John G. Smith 1 and Mr. Soden 2 have 
shown by a number of dissections, is to allow the head of the humerus 
to be drawn upwards and forwards in its socket, until it is arrested by 
the two processes, and by the coraco-acromial ligament. Says Mr. 
Soden, " To enable the bone to maintain its equilibrium, it is necessary 
that the capsular muscles should exactly counterbalance each other ; 
and as there is no muscle from the ribs to the humerus to antagonize 
the upper capsular muscles " (that is, to draw the head of the humerus 
downwards), u it is suggested that this office is performed by the sin- 
gular course of the long tendon of the biceps, which, by passing over 
the head of the bone, when the muscle is put in action, tends to throw 
the head downwards and backwards ; it follows, therefore, that, the 

1 Amer. Journ. Med. Sci., vol. xvi, p. 219, May, 1835, from Lond. Med. Gaz. 

2 Ibid., vol. xxix, p. 480, from Lond. Med. Gaz., July, 1841. 



PARTIAL DISLOCATIONS OF THE HUMERUS. 



615 



Fig. 272. 



tendon being removed, the head of the bone would rise upwards and 
forwards." 

The drawing (Fig. 272) represents the case of displacement of the 
tendon of the biceps seen by Mr. Soden, and of which he had beon per- 
mitted to make a dissection. 1 

I have myself frequently observed, and I have before, when speak- 
ing of the prognosis or results of dislocations, called attention to the 
fact, that the head of the humerus 
sometimes remains for a long time 
after the reduction has been effected 
slightly advanced in its socket, so as 
to lead to a suspicion that it is not 
properly reduced. Quite recently I 
have been consulted in the case of a 
lad about fourteen years of age, who 
had been subjected to the pulleys 
during four consecutive hours to ac- 
complish a more complete reduction. 

The same thing, also, has been 
noticed by me occasionally where 
the shoulder had been subjected to 
a violent wrench, but no actual dis- 
location had ever occurred. In either 
case the explanation is perhaps the 
same, the long head of the biceps has 
been broken or displaced; or, when it follows a dislocation, some of the 
muscles inserted into the greater tuberosity have been torn from their 
attachments. I mean to say that in these circumstances we may find 
a sufficient and perhaps the most frequent explanation ; yet it is quite 
probable that, in a considerable number of cases, the laceration of the 
capsule, and the action of the muscles, are alone concerned in the pro- 
duction of this phenomenon. I have seen one example in the person 
of Mr. Craig, of Brooklyn, in which the tendon of the biceps suddenly 
resumed its position after the lapse of several days, and the prominence 
of the head of the humerus at once disappeared. 

Alfred Mercer, of Syracuse, N. Y., in a very interesting paper on 
this same subject, relates several examples of forward displacement 
after injuries to the shoulder-joint, one of which, as being exceedingly 
pertinent, I shall take the liberty of quoting. 

"Mrs. B., a well-developed woman, of full habit, aged fifty-six,. seven 
years since was thrown from a carriage, dislocating her right shoulder, 
which was reduced a short time after the accident, but the shoulder 
was painful, and tender to the touch, and almost useless for months 
after. She could carry the arm forwards and backwards, but could 
not raise it from the side, or carry the hand behind her, or raise it to 
her head, for fourteen months. She has gradually gained better use of 




Displacement of the long head ot the biceps. 



1 Pirrie's System of Surg., Arner. ed. : 
Bransby Cooper, Amer. ed., p. 363. 



p. 255 ;. also,. Sir Astley Cooper, edited by 



- 



616 DISLOCATIONS OF THE SHOULDER. 

her arm, but now, July, 1858, she cannot raise her elbow from the 
side more than half-way to a horizontal position without assistance ; 
but with assistance, the arm may be carried into any position without 
pain or resistance. Measurement shows no appreciable difference in 
the size or length of the arm, or size of the shoulder; but the point of 
the shoulder is still tender to the touch, is prominent in front, and cor- 
respondingly flattened behind. The head of the humerus appears to 
rest against the outside of the coracoid process, but the fulness of habit 
obscures the diagnosis, compared with the other cases. Several doctors, 
at different times, have examined the shoulder; some have said it was 
not properly reduced, and advised a suit for malpractice. 

"I examined the shoulder again in November last; it presented the 
same general appearance, although the patient was much thinner in 
flesh from recent sickness. Some six weeks previous to this examina- 
tion, in a sudden and thoughtless effort to raise the arm above the head, 
the muscles unexpectedly obeyed the will ; since which time she has 
had perfect use of it, though the deformity still remains. She thinks 
she felt or heard a snap when the arm went up, but it was followed by 
no pain, soreness, or swelling." 1 

There can be no doubt, we think, that in this case, at least, the de 
formity and maiming were due in a great measure to a displacement 
of the long head of the biceps. 2 

If a displacement of the tendon necessarily causes a displacement of 
the head of the humerus, it might seem proper to infer that a rupture 
of the tendon would do the same. The only example of rupture of the 
tendon which has come under my observation does not confirm this 
opinion. 

James Wallace, set. 46, a sailor, and a man of remarkable muscular 
development, while pushing a swing with his arms extended felt some- 
thing snap in his right arm, and the arm at once became powerless. 
The sensation of snapping was at a point about four and a half inches 
below the acromion process. The pain was like that caused by hitting 
a nerve ; on the following day there was an extensive ecchymosis over 
the upper end of the humerus, and the belly of the biceps was full and 
flabby. 

Wallace was examined by me at Bellevue in March, 1875, about 
eight months after the injury was received. The belly of the biceps had 
shortened upon itself, and made a very remarkable prominence on the 
front of the arm, but he could not render it firm by contraction. He 
can flex the forearm slowly but not against any considerable resistance. 
The head of the humerus is not advanced in the socket. I can feel the 
tendon of the biceps in its groove, and infer that the rupture took 
place near its insertion into the muscle. 

1 Mercer, Buffalo Med. Journ., vol. xiv, p. 641, April, 1859. 

2 Broomfield's Chirurg. Observ., vol. ii, p. 76. 



DISLOCATIONS OF HEAD OF RADIUS FORWARDS. 617 



CHAPTEE VII. 

DISLOCATIONS OF THE HEAD OF THE RADIUS (HUMERO- 
RADIAL). 

I have met with twenty-six examples of traumatic dislocation of 
the head of the radius ; of which nineteen were dislocated forwards, 
or forwards and outwards, and only four backwards: or, rejecting 
those cases which were complicated with fracture, I have recorded 
ten cases of simple forward luxation, and two of simple backward 
luxation. My experience, therefore, does not correspond with the 
experience of Boyer, Yelpeau, Vidal (de Cassis), Chelius, B. Cooper, 
Guthrie, Gibson, and some others, who declare that the dislocation 
backwards is the more frequent of the two. Indeed, I ought to say 
of both of the examples of backward luxation of the radius which 
have come under my notice, and which I have marked as simple, that 
they were ancient luxations, and I am not entirely certain, therefore, 
that they had not been originally complicated with a fracture, although 
at the time of my examination they presented no such evidence. I ■ 
have seen one congenital dislocation of the head of the radius outwards 
and forwards, which I will describe more particularly in the chapter on 
congenital dislocations. 

I 1. Dislocations of the Head of the Radius Forwards. 

Causes. — A fall upon the elbow, the blow being received directly 
upon the posterior face of the head of the radius; a fall upon the hand 
with the forearm extended and pronated ; extreme pronation of the 
forearm ; or, according to Denuce, a blow upon the inside of the elbow, 
which is equivalent to a violent adduction of the forearm. 

In children, and especially in those of a strumous habit, whose liga- 
ments are feeble, a subluxation forwards, or even a complete luxation, 
is occasionally produced by being lifted suddenly from the floor by the 
hand, or by an attempt to sustain the child when he is about to fall. I 
have seen examples of this dislocation produced in this way. Batch- 
elder, 1 Sylvester, 2 Goyrand, 3 and many other surgeons, have mentioned 
similar cases. In the case of Lydia Merton, four years old, brought 
to me in May, 1868, the dislocation was caused by holding on by the 
hands after having fallen from a swing. 

Dr. Krackowizer related to the New York Academy, in 1856, a 
case of complete dislocation forwards, produced, as was supposed, in 

1 New York Journ. Med., May, 1856, p. 333. 

2 Amer. Journ. Med. Sci., vol. xxxi, p. 206, Jan. 1843. 

3 Ibid., vol. xxxii, p. 228, July, 1843. 

40 



618 DISLOCATIONS OF THE HEAD OF THE RADIUS. 






the act of turning the child in delivery. The arm was ecchymosed, 
and the dislocation was very distinct. 1 

Pathological Anatomy. — The head of the radius is carried forwards 
upon the humerus, and generally a little outwards. In the case of 
Lydia Merton, already mentioned, the head of the radius, on the ninety- 
fourth day after the accident, was nearly in the centre of the humerus. 
The anterior and external lateral ligaments, with the annular, are in 
most cases more or less broken. Sometimes the anterior and external 
lateral are alone broken, the annular ligament being then sufficiently 
stretched to allow of the complete dislocation ; or the anterior and 
annular having given way, the external lateral may remain intact. 

Symptoms. — The head of the radius can in general be distinctly felt 
in its new situation, rotating under the finger when the hand is pro- 
nated and supinated ; we may sometimes also recognize a depression 
corresponding to its natural situation, behind and below the little head 
of the humerus. The external border of the forearm is slightly short- 



Fig. 273. 



Fig. 274. 





Head of radius forwards, 
relations. 



Anatomical 



Head of radius forwards. External appearance 
of limb. 



ened, and the arm inclines unnaturally outwards. The tendon of the 
biceps is relaxed. The forearm is generally pronated, sometimes it is 
in a position midway between supination and pronation, but I have 
never seen it supinated. I have particularly noticed this fact in my 



1 Krackowizer, New York Journ. Med., March, 1857, p. 262. 



DISLOCATIONS OF HEAD OF KADIUS FORWAEDS. 619 

report made to the New York State Medical Society in 1855 ; and 
Denuce, who has also examined these cases carefully, affirms that it is 
seldom supinated, notwithstanding the general statements of surgeons 
to the contrary. 

The arm is usually a little flexed, and cannot be perfectly extended 
without causing pain. In some cases, especially when the dislocation 
has existed for a considerable length of time, the arm is capable of 
extreme and unnatural extension. This was the case with Lydia 
Merton. There is usually preternatural lateral motion ; but, except in 
old cases, the forearm cannot be flexed upon the arm beyond a right 
angle. 

Prognosis. — Denuce" says : "The reduction is often impossible; more 
frequently still, difficult to maintain." In proof of which he refers to 
the observations of Danyau and Robert. In the case of recent luxa- 
tion related by Robert, it was found impossible to maintain a reduc- 
tion which he thought he had several times accomplished, and he 
believed that the difficulty consisted in a portion of the torn annular 
ligament having become entangled between the head of the radius and 
the condyle of the humerus. 1 

Sir Astley Cooper was unable to accomplish the reduction in two 
recent cases; and of the six cases which came under his immediate ob- 
servation, only two were ever reduced. In Bransby Cooper's edition 
of Sir Astley's work, other similar examples of non-reduction are 
related. 

Malgaigne says that in a collection of twenty-five cases which he 
has made, the accident was unrecognized or neglected in six, and in- 
effectual efforts at reduction had been made in eleven ; so that only 
eight of the whole number were reduced. 

I have myself met with six of these simple dislocations which were 
not reduced, three of which, however, had not been recognized, and no 
attempts at reduction had ever been made; one had been treated by an 
empiric, Sweet, a "natural bone-setter," but without success; one had 
been reduced, but it had become reiuxated, and in the remaining ex- 
ample I was myself unable to reduce the dislocation on the seventh day. 

The following are brief notes of four of these cases : 

A young man, set. 23, presented himself at my office, to whom the 
accident had occurred about one year before. The surgeon who was 
first called did not recognize the dislocation, and no attempt had ever 
been made to replace the bones. The forearm was forcibly pronated 
and could not be supinated, but he could extend it completely, and flex 
it somewhat beyond a right angle. It was strong, and nearly as useful 
as before. 

H. H. B., set. 6 ; dislocation produced by a fall upon the elbow. 
The surgeon who was called did not detect the nature of the injury. 
Eighteen years after, I found the head of the radius lying in front of 
the old socket, having formed a new socket, in which it moved freely. 
From the elbow to the hand the arm inclined outwards, or to the 
radial side; pronation and supination were perfect. He could flex the 

1 Memoire sur les Luxations du Coude, par Paul Denuce. Paris, 1854. 



DISLOCATIONS OF THE HEAD OF THE RADIUS. 



arm to an acute angle, but not so completely as the other. The arm 
was as strong as the other, but it was frequently hurt by lifting. 

Ira E. Irish, set. 12. "Sweet" was at first employed, but failed to 
reduce it. Thirty-nine years after, when Mr. Irish was fifty-one years 
old, I examined the arm. He could not flex the forearm upon the arm 
beyond a right angle ; and when the attempt was made, the radius 
struck against the humerus. Complete supination was impossible. 
The arm was as strong as the other, except in raising a weight above 
his head. Occasionally he was annoyed with slight pains in this limb. 

Urias Lett, a colored barber of Buffalo, aged forty-eight years, was 
thrown from a carriage, producing dislocation of the right radius, and 
severely bruising the elbow-joint. He drove a couple of spirited horses 
several miles after the accident, and did not see Dr. K., a highly ac- 
complished young surgeon, until six hours had elapsed. The elbow 
was then much swollen, and exquisitely tender, and Lett would not 
permit much if any examination, to enable Dr. K. to determine hi 
condition. The Doctor applied simple dressings, and the next day re 
quested me to see him. The whole arm was then swollen and tender 
and very little examination was admissible. The dressings wem 
therefore, not completely removed, but only laid open sufficiently to 
enable us to see the joint. We suspected a forward luxation of the 
head of the radius, but could not positively determine the point — the 
patient not permitting any kind or degree of manipulation. We de- 
cided, therefore, to wait a few days until the inflammation had some- 
what abated, and then, if the existence of a dislocation was ascertained, 
to attempt its reduction. On the seventh day the swelling had meas- 
urably subsided, and the diagnosis became satisfactory. We immedi- 
ately placed him under the complete influence of chloroform, and made 
long-continued and violent efforts at reduction, but without success. 
Severe inflammation again followed these efforts, and Lett would never 
consent to another trial. After four years, I find the bone still out. 
He can flex the forearm upon the arm almost as far as he can the op- 
posite limb; he can carry it nearly to his mouth, the head of the 
radius sliding off upon the outer face of the. humerus, and not resting 
plumply against it; indeed, the radius seems to have been gradually 
pushed outwards as well as forwards. The hand is forcibly pronated, 
and cannot be supinated. The attempt to supine produces a click in 
the neighborhood of the head of the radius, as if it struck against a 
bone. The arm is as strong as the other, and not wasted. He has 
constantly pursued his occupation as a barber, after only a few weeks' 
confinement. 

If the dislocation is accompanied with a fracture of the ulna, unless 
the fracture is transverse or incomplete, reduction is not generally ac- 
complished. When speaking of fractures of the shaft of the ulna, I 
have related several examples illustrative of this remark. Norris has 
made the same observation. 1 I have, however, three times met with 
this accident thus complicated in children, in the treatment of which a 
much better result has been obtained. In the first example, a lad aged 



t 

; 



1 Norris, Amer. Journ. Med. Sci., vol. xxxi, p. 21. 



DISLOCATION OF HEAD OF RADIUS FORWARDS. 621 

nine years had broken the nlna in its upper third and dislocated the 
radius forwards. Dr. "White, of Buffalo, and myself were in imme- 
diate attendance. Both the fracture and dislocation were easily re- 
duced, and in a few weeks the limb was sound and perfect, except that 
a slight fulness remained in front of the head of the radius, and this 
continued for several years. In the second example, a lad, of the same 
age as the other, was treated by Dr. Austin Flint and myself. We 
reduced both the fracture and the dislocation by extending the arm 
from the wrist, while at the same moment pressure was made upon the 
head of the radius from before backwards. A right-angled splint was 
applied and continued during a period of four weeks, being removed 
daily for the purpose of giving to the joint gentle, passive motion, etc. 
After this the arm was permitted to straighten gradually, and at the 
end of a month more the joint was moving freely, and with no degree 
of displacement at the point of fracture or dislocation. 

It is quite probable that in each of the above cases the separation 
was not complete, although crepitus was distinct, and the displacement 
of the broken ends was very marked. In the following case the frac- 
ture was certainly incomplete : 

Elizabeth Carmody, set. 4, was brought to me, August 6, 1851, with 
a fracture of the ulna, two inches below its upper end, the fragments 
being inclined backwards, while the radius was dislocated forwards. 
Both bones were easily replaced, and the functions of the arm were 
soon completely restored. 1 

Where the restoration has been promptly effected and maintained 
steadily, the motions of the joint are soon restored ; but in one case 
the head of the radius has been found to play very freely and loosely 
after the lapse of two years, and in others it has remained slightly 
prominent in front, as if it was a little in advance of its socket. 

Treatment. — Extension and counter-extension should be made in the 
direction in which we already find the limb, namely, with the forearm 
slightly bent upon the arm, while at the same moment the surgeon 
should seize the elbow with his hands, and press the head of the radius 
back with his two thumbs. 

Other methods will often succeed ; but by this we relax the biceps, 
and put the parts in the best position to accomplish the reduction easily 
and promptly. Sir Astley directed to supine the forearm while the 
extension was being made from the hand, but Denuce prefers that the 
forearm should be in a position of pronation. 

After the reduction is effected it is never safe to straighten the arm 
completely at once, nor indeed for some weeks ; not until the ligaments 
have been sufficiently restored to resist the action of the biceps. The 
arm must therefore be flexed and placed in a sling, or, if the radius is 
disposed to become reluxated, a right-angled splint ought to be placed 
upon the back of the arm and forearm, and, by the aid of a compress 
and roller, an attempt should be made to retain it in place. 

Xor will it be found safe at any period to compel the arm by force 

1 This case was erroneously reported to the New York State Medical Society as 
an example of fracture of the radius, with dislocation. 



622 



DISLOCATIONS OF THE HEAD OF THE RADIUS. 



to resume the straight position, since this bone, when it has once bee 

dislocated, will for a long time be liable to luxation. 

A boy, aged about four years, was presented at my clinic by hi 
father, having a forward dislocation of the head of the radius. Th 
dislocation had existed several months. The father's purpose in bring 
ing the child was to ascertain whether he could not claim damages for 
malpractice. The account which he gave was as follows : The surgeon 
called it a dislocation forwards, and pretended to reduce it. A right- 
angled splint was applied with a roller. At the end of three weeks 
the father removed the splint, but did not discover anything out of 
place. Finding, however, that the elbow was stiff, he took measures 
to straighten it forcibly. In a few days he discovered the head of the 
bone out of place, and so it has remained ever since. 

I explained to him that there was much reason to suppose that the 
surgeon had properly reduced the dislocation, and that he had himself 
reproduced the accident, by straightening the arm, through the action 
of the biceps upon the upper end of the radius. The father declined 
any further surgical interference, and no prosecution has followed. 

_ The late Dr. Batchelder, of this city, in a very excellent paper 
dislocations of the head of the radius, has described a method of red 
tion suggested to him first by Dr. Goodhue, of Chester, Vermont, *.„., 
which he had himself found more successful than any other method ; 
indeed, he says it never fails, yet he does not inform us in precisely 
how many cases he had made the trial. The plan suggested by Dr 
Goodhue consists essentially in first making extension from the hand 
and pressing at the same time downwards and backwards upon th 
head of the radius until it has descended to a level with the articulating 
surface of the humerus. As soon as this is accomplished, the forearm 
is to be suddenly flexed upon the arm in such a direction as that the 
hand shall pass outside of the shoulder; at the same moment, also, the 
pressure must be continued vigorously upon the head of the radius. 1 



er on 
•educ- 
t, and 



I 2. Dislocation of the Head of the Radius Backwards. 

Denuce has collected fourteen examples of this luxation ; but Mai- 
gaigne, who rejects a portion of the cases, and adds one or two more, 
admits only twelve. In addition to those mentioned by these two 
writers, I have found recorded, or incidentally noticed, one by May, 2 
one by Bransby Cooper, 3 one by Lawrence, 4 one by Liston, 5 two by 
Case, 6 two by Gibson, 7 one by Parker, 8 three by Markoe, 9 and to these 



1 Goodhue, New York Journ. of Med., May, 1856, p. 333. 

2 May, Sir Astley Cooper on Dislocations, etc , by B. Cooper, op. cit., p 403 

3 B Cooper, ibid., p. 404. < Lawrence, Pirrie's System of Surgery, p. 259 

5 Liston, Practical Surgery, p. 88. ^'i 

6 Case, Amer. Journ. of Med. Sci., vol. vi, p. 254, from 11th No. of Provincial 
Med. Gazette. 

T Gibson, Institutes and Practice of Surgery, 6th ed., vol. i, p. 379. 

8 Parker, New York Journ. of Med., March, 1852, p. 188. 

9 Markoe, ibid., May, 1855, p. 382. 



DISLOCATION OF HEAD OF RADIUS BACKWARDS. 623 

my own observations have added four more, in all twenty-eight sup- 
posed examples. 

Of the examples brought under my own notice I have already in 
the preceding section affirmed that two of them were accompanied 
with fracture, and I am not entirely certain but that they all were. 
Markoe, of New York, whom we have mentioned as having reported 
three cases, found in each case a fracture of the internal condyle of the 
humerus, and, after an examination of a number of the reported ex- 
amples, he does not find any evidence that this dislocation ever occurs 
as a simple uncomplicated accident. I am unable to complete the 
critical analysis which Dr. Markoe has undertaken ; yet I confess that, 
so far as I have been able to do so, the testimony strongly confirms his 
conclusion. "While I am prepared to admit the possibility of the lux- 
ation without either a fracture of the lower end of the humerus or of 
the ulna, I have found no written account of any case, nor have I seen 
an example, which was absolutely conclusive. 

The example reported by Parker as having occurred in the practice 
of X. K. Freeman, of this city, is one of the few which seems to admit 
of but very little doubt. 

In July, 1850, Dr. Freeman was called to see a gentleman, set. 37, 
who was seriously injured by jumping from the railroad cars while 
they were in motion, and found a backward luxation of the head of 
the radius of the right arm. " The symptoms," says Dr. Freeman, 
" were marked ; the hand and forearm were prone, and the attempt to 
place them in the supine position caused great pain ; while the head of 
the radius formed a considerable projection posterior to the external 
condyle of the humerus, where the cavity on its extremity could be 
distinctly felt. Assisted by Dr. Walsh, of Fordham, who firmly 
grasped the humerus, I was enabled to reduce it by extending the 
forearm and flexing it upon the arm, at the same time pronating the 
hand, and pressing forwards the head of the radius with my thumb. 
After the reduction was effected, I requested Dr. "Walsh to examine it; 
when, upon slight extension being made upon the forearm, with supi- 
nation of the hand, the bone was again dislocated. I immediately re- 
duced it in the same manner as before, and directed the patient to keep 
the forearm flexed and the hand prone, and, laving it upon a pillow, 
apply cold water. He complained of severe pain for two days, which 
gradually subsided, and on the fourth day he was able to move and 
extend the forearm." 

Causes. — A direct blow upon the front and upper part of the radius ; 
a fall upon the elbow, or upon the hand; a violent effort to supinate 
the forearm while it is grasped and held firmly in a state of pronation ; 
probably, also, sometimes it is occasioned by a twisting of the arm in 
machinery, etc. 

Pathological Anatomy. — In the only example of which a dissection 
has been made, reported by Sir Astley Cooper, " the coronary ligament 
was found to be torn through at its forepart, and the oblique had given 
way. The capsular ligament was partially torn, and the head would 
have receded much more, had it not been supported by the fascia which 
extends over the muscles of the forearm." The head of the radius 



624 DISLOCATIONS OF THE HEAD OF THE RADIUS. 



Fig. 275. 



was thrown behind the external condyle of the humerus, and rather to 
the outer side. This was an ancient luxation found in the dissecting- 
room of St. Thomas's Hospital,, and the accompanying drawing is 
copied from the sketch made at the time. 

If the luxation is not complete, as occasionally happens with chil- 
dren, the annular ligament may not be torn. 

Symptoms. — The head of the bone is felt rotating behind the outer 
condyle, and a depression exists corresponding to its original position. 
The forearm is slightly flexed and prone; and 
the whole arm is deflected outwards from the 
elbow downwards ; flexion and extension are diffi- 
cult, while supination is impossible. 

Treatment. — Most surgeons have agreed that 
while extension and counter-extension are being 
made, the forearm should be forcibly supinated. 
At the same time, also, the head of the radius 
must be strongly pushed forwards. Martin rec- 
ommends to extend forcibly, and then suddenly 
flex the arm, in a manner very similar to the plan 
recommended by Batchelder in dislocations for- 
wards. In Dr. Freeman's case, just quoted, the 
reduction was effected while the forearm was pro- 
nated, and supination seemed to throw it again 
out of place. 

According to Markoe, where the accident is 
complicated with a fracture of the inner condyle, 
when the reduction is accomplished the arm 
should be placed in a position about ten degrees 
less than a right angle, and supported by a splint 
with bandages, etc. 

If the dislocation is simple, however, I can see 
no objections to its being nearly or quite extended, since in this dislo- 
cation the action of the biceps would only tend to retain the head of 
the radius in place. 




Dislocation of the head of 
the radius backwards. 



2 3. Dislocation of the Head of the Radius Outwards. 

Denuce" has collected four examples of this accident, unaccompanied 
with a fracture, and he proceeds to speak of it as a distinct form of 
dislocation. In two of the examples, however, mentioned by him, it 
was consecutive upon a forward luxation, and I have several times 
seen the head of the radius very much inclined outwards in what are 
properly termed forward dislocations. For these reasons it is not very 
plain to me that we ought to consider this as a distinct form of pri- 
mary dislocation, but rather as a consecutive luxation, or at least as 
only a modification of the forward or backward luxation. Indeed, I 
think the radius never will be found thrown directly outwards, but 
always in a direction inclining forwards or backwards. 

Parker, of this city, mentions a case which came under his notice, 
in a child four years old, who, six weeks before, had fallen down stairs 



DISLOCATIONS OF UPPER END OF ULNA BACKWARDS. 625 

" backwardly, with the right arm twisted behind the back, in such a 
position that the whole weight of her body came upon her arm." No 
attempt was ever made to reduce the bone, and the head of the radius 
continued to project externally. By pressure it was easily reduced, 
but became immediately displaced when the forearm w T as either flexed 
or extended. The motions of the joint were completely restored. Dr. 
Parker recommended no treatment. 1 



CHAPTER VIII. 

DISLOCATIONS OF THE UPPEK END OF THE ULNA (HUMEKO- 

ULNAE). 

Dislocation Backwards. 

This accident, the existence of which, as a simple luxation, is placed 
beyond doubt, has nevertheless been described so variously, and often 
indefinitely, that it is impossible to declare its history, except in a few 
points, with any degree of accuracy. No doubt many of the cases 
which have been reported were examples only of a subluxation of both 
radius and ulna backwards. In other cases, the radius or the external 
condyle of the humerus being broken, the ulna has been actually dis- 
placed, not only backwards, but upwards ; indeed, it is very certain 
that without either a luxation of the radius, or a fracture with displace- 
ment of the external condyle of the humerus, or a fracture or bending 
of the radius, an upward displacement of the ulna, to the degree repre- 
sented by the reporters of these cases, could never have occurred. The 
example mentioned by Sir Astley Cooper, and of which a dissection 
was made, is plainly a case of subluxation of both bones ; or if the lux- 
ation of the ulna may be regarded as having been complete, the head 
of the radius was also displaced more or less upwards from its original 
socket, a new socket, Sir Astley himself informs us, having been formed 
for its reception, upon the external condyle. But this is the only ex- 
ample, the actual condition of which has been proven by an autopsy. 

Nevertheless, it seems probable that a simple luxation or subluxa- 
tion of the ulna backwards may occur without either of the above- 
mentioned complications, and that, to .the extent of a few lines, it may 
be made to pass upwards upon the back of the humerus, by the falling 
of the forearm to the ulnar side ; in which case the character of the 
accident would probably be recognized by the projection of the olec- 
ranon process, while the head of the radius might be felt moving in 
its socket ; by the partial flexion and complete pronation of the forearm, 
and by the general immobility of the joint. In a case reported by Dr. 

1 Parker, New York Journ. Med., March, 1852, p. 189. 



626 DISLOCATIONS OF THE RADIUS AND ULNA. 

Waterman, caused by a fall on the hand, the arm was at a right angl 
and pronated. 1 

Its reduction ought to be accomplished easily, one would think, bj 
the same measures which have been found successful in reducing 
dislocation of both bones backwards; but in Waterman's case this 

Fig. 276. 




Dislocation of the upper end of the ulna backwards. 

method failed, and the reduction was promptly effected by bending 
the forearm forcibly back. 

Pirrie says that in a case occurring in the practice of Mr. Gosset, in 
which the coronoid process rested on the internal condyle, and the pain 
on bending the arm was insupportable, owing, it was supposed to the 
pressure of the coronoid process against the ulnar nerve, " reduction 
was accomplished by extension and counter-extension applied by two 
persons pulling in opposite directions, and by the pressure of the olec- 
ranon process downwards and outwards, while the forearm was sud- 
denly flexed." 2 



CHAPTER IX. 



DISLOCATIONS OF THE RADIUS AND ULNA (FOREARM AT 
THE ELBOW-JOINT). 

The radius and ulna may be dislocated at the elbow-joint back- 
wards ; laterally, that is, either inwards or outwards ; and forwards. 

8 1. Dislocations of the Radius and Ulna Backwards. 

Causes. — In sixty cases observed and recorded by me, the average 
age is about twenty years ; the youngest being four years old, and the 
oldest fifty-three. Twenty-three of this number occurred in children 
under fourteen years of age. 

Generally the dislocation has been produced by a fall upon the palm 
of the hand, as when in running a person has fallen forwards with the 
forearm extended in front of the body, or he may have fallen from a 

1 Boston Med. and Surg. Journ., vol. iv, new series. 

2 Gosset, Pirrie's Surg., Amer. ed., p. 259. 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 627 



Fig. 277. 




height; once I have known it produced by a blow received upon the 
back and lower part of the humerus ; and in several instances the 
patients have declared that they had fallen upon the elbow ; it is pro- 
duced, occasionally, by twisting the forearm violently, as when the 
limb has been caught and wrenched about by machinery, by a blow 
upon the front and upper part of the forearm, and by forced flexion. 

Pathology. — The radius and ulna are not only carried backwards 
behind the articulating surface of the humerus, but they are also, 
through the action of the triceps, almost 
always drawn more or less upwards, so that 
often the coronoid process of the ulna rests 
in the olecranon fossa. In some cases it has 
been known to mount even higher, while in 
others it is arrested short of this point. The 
radius still retaining its relative position to 
the ulna, lies upon the back of the humerus, 
or rather upon the posterior margin of its 
articulating surface. 

The anterior and two lateral ligaments 
are generally more or less completely torn 
asunder; but the posterior ligament and the 
annular do not usually suffer disruption. 

The biceps muscle is drawn over the lower 
articulating surface of the humerus, but is in 
a condition of only moderate tension, while 
the brachialis anticus is forcibly stretched, 
or even torn. 

The median nerve is also pressed upon in front by the humerus, and 
the ulnar is occasionally painfully stretched over the projecting ex- 
tremity of the ulna from behind. 

Symptoms. — Sir Astley Cooper does not mention particularly the 
position of the arm as to flexion or extension, except to say that " the 
flexion of the joint is in a great degree lost;" nor, in his original work, 
published in London in 1823, is there any illustration accompanying 
the text to indicate in what position he had usually seen the limb; but 
in the later editions, edited by Mr. Bransby Cooper, is found a drawing 
which represents the forearm at a right angle with the arm. It is very 
certain that Sir Astley never sanctioned this error by anything which 
he had written or communicated to others. It is very certain, I say, 
because the fact that it seldom, if ever, occupies this position, could 
not have escaped the notice of one whose experience was so large, and 
whose habits of observation were generally so accurate. The truth is 
that it is almost constantly found only slightly flexed, or forming an 
angle in front of about 120°. 

This fact is especially noticed in my records twenty-six times, and 
if it had ever been found in any other position, it would certainly have 
been stated. Once, where the dislocation was accompanied with a 
fracture of the outer condyle of the humerus, the arm was at first 
straight, a position in which it is said to be found occasionally with 
children ; and in the case of a patient admitted to Bellevue Hospital, 



Dislocation of the radius and 
ulna backwards. 



628 



DISLOCATIONS OF THE RADIUS AND ULNA. 



on the 14th of December, 1864, the dislocation having existed thirty- 
one days, but unaccompanied with a fracture, I found the arm straight, 
and there existed also a preternatural lateral mobility of the elbow- 
joint ; but never, in any case of a recent dislocation, and but once in 
an old dislocation, have I found it flexed to a right angle ; yet I will 
not deny that such unusual phenomena are possible in recent disloca- 
tions; indeed, it is certain that they have occasionally been presented, 
but they must be regarded as only exceptional, and as by no means 
diagnostic of this accident. 

Sir Astley Cooper and Miller declare that in this dislocation the 
forearm is usually supinated; Pirrie says "the hand is between prona- 
tion and supination, but more inclined to the latter." Desault thinks 
it is sometimes in supination and sometimes in pronation; Den uce con- 
cludes that it will occupy that position, whatever it may be, in which 
the force of the blow has thrown it; while by most surgical w r riters no 
allusion is made to the position of the forearm in reference to pronation 
or supination. For myself, I can only say that I have found the fore- 
arm and hand almost constantly in a position of moderate but positive 
pronation, and I am compelled to regard it,, therefore, as one of the 
usual signs of a backward dislocation of these bones. 

The limb can be neither flexed nor extended without force, and such 
motion is almost always accompanied with pain. It is, however, pos- 
sible in most cases to give to the arm a slight lateral motion, such as 
does not belong to it in its natural condition. 

In front, and deep in the fold of the elbow, is felt the lower end of 
the humerus, forming a hard, broad, and somewhat irregular projection, 
over which the integuments and muscles are swollen, and tender to 
pressure. Behind, the head of the radius may be felt, when not much 
tumefaction exists, rotating or moving under the finger when the fore- 
arm is supinated and pronated ; while the olecranon process projects 
strongly backwards and upwards. If now we flex the arm slightly, 
this projection of the olecranon process will be sensibly increased ; but 
if an attempt is made to straighten the arm, it will be diminished, the 
reverse of what we have seen to happen in cases of fracture of the lower 
end of the humerus (at the base of the condyles). This circumstance 
becomes, therefore, an important diagnostic mark between these two 
accidents. 

The relation of the olecranon process, also, to the condyles is changed, 
and the upper end of this process, instead of being a little below the 
internal condyle, as it would be naturally when the arm is slightly 
flexed, is found generally carried upwards toward the shoulder, from 
half an inch to one inch or more above the condyle. 

Measuring from the internal condyle to the styloid process of the 
ulna, the forearm is shortened ; the same result will be obtained also 
by measuring from the acromion process to either of the styloid pro- 
cesses; while from the acromion process to the condyle, the length will 
be the same in both arms. 

The signs which have now been enumerated will be sufficient to 
enable us to make the diagnosis promptly in the great majority of 
cases, but if considerable swelling has already taken place, the diag- 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 629 

nosis may be rendered exceedingly difficult, if not impossible ; and in 
such cases we should confine the patient at once to his bed, and proceed 
to reduce the tumefaction by cold water lotions as rapidly as possible, 
examining the limb carefully from day to day in order that we may 
seize the earliest opportunity to ascertain its actual condition and apply 
the proper remedy. 

In relation to the difficulty of diagnosis in certain examples of this 
accident, and under certain circumstances, Mr, Skey, in his Operative 
Surgery, has made some very judicious remarks. 

" Severe injuries of the elbow-joint, whether in the form of fracture, 
dislocation, or a compound of the two, are frequently followed, at a 
short interval, by swelling of a formidable kind, in which it is impos- 
sible, but by the aid of a perfect intimacy with the anatomical structure 
of the joint, to detect the relations of one part with another; but even 
under this difficulty, the two points in question are readily distinguish- 
able. In such forms of swelling, the arm, including the length of six 
inches both above and below the joint, may be involved in the extrava- 
sation, and this swelling may distend the arm to a circumference of 
one-third beyond its natural size. In such circumstances, in which it 
is impossible to determine with any certainty whether any, or what 
bones are broken, or whether or not dislocated, the difficulty of the case 
should at once be stated to the friends of the patient" 

Prognosis. — If the luxation is recent, reduction is in general easily 
effected ; but if considerable time has elapsed, the reduction is often ac- 
complished with difficulty. As to the probability of its reluxation, I 
have already spoken when considering the subject of fractures of the 
coronoid process. Unless this process is broken, it is not likely to occur 
except where some violence has again been applied. It has happened 
to me, however, to find these bones unreduced in several instances. In 
some of these examples surgeons recognized the accident and supposed 
that they had accomplished reduction, while in others the dislocation 
was mistaken for a fracture. 

A lad, TT. F., twelve years old, residing in Erie County, N, Y., 
was brought to me six weeks after the accident had occurred. The sur- 
geon who was first called declared it to be a dislocation, and told the 
parents he had reduced it; but the dislocation was now complete, and 
the arm immovablv fixed in its abnormal position. 

On the 10th of May, 1850, J. P., of Canada West, set. 25, was thrown 
from a load of hay, striking upon his left hand, and producing a dislo- 
cation backwards of both bones at the elbow-joint. A Canadian sur- 
geon, who saw the patient within three hours, recognized the disloca- 
tion, and by pulling the arm straight forwards he supposed he had 
reduced it ; the patient also thought he felt the bones slip into place. 
No attempt was made subsequently to flex the arm, and it was imme- 
diately dressed with a straight splint laid along the palmar surface. 
On the sixth day it was found to be unreduced, and the surgeon again 
attempted to reduce it as before, and thought he had succeeded. The 
same splint was reapplied. At about the end of six weeks three sur- 
geons, residing in Canada also, placed the patient under the complete 
influence of chloroform, and attempted the reduction. They first made 



630 



DISLOCATIONS OF THE RADIUS AND ULNA. 



extension for half an hour in a straight line, then five men seized upon 
the arm and forearm, bending it with great force to a right angle. It 
was now believed that the ulna was reduced, but not the radius. Four 
days after, the attempt was renewed. Three months after the accident 
the young man called upon me, and I found the arm nearly straight, 
with almost complete anchylosis at the elbow-joint. Both the radius 
and ulna were displaced backwards, but not upwards. The arm was 
of the same length with the other, and the relation of the condyles to 
the olecranon was so manifest, that the absence of the usual displace- 
ment upwards was easily determined. I was unwilling to make any 
further attempts at reduction, not believing that I should succeed after 
so much time had elapsed, and after so many ineffectual attempts had 
been made by clever surgeons. 

In the following examples the dislocation was supposed to have been 
a fracture of the lower end of the humerus. 

A man, residing in Pittsfield, Mass, dislocated his left arm by fall- 
ing from a horse. The surgeon who was called regarded it as a frac- 
ture at the base of the condyles, and treated it accordingly. Ten weeks 
after, the error was discovered and an attempt was made to reduce 
it, but without success. A second attempt was also made, with the 
same result. 

The patient was brought to me eight months after the accident, with 
the bones still unreduced. The forearm hung at a very obtuse angle 
with the arm, and there was very slight motion at the elbow-joint. I 
discouraged any further attempts at reduction. 

Mr. W., of Alleghany Co., N. Y., set. 43, fell from a load of hay, 
striking upon his left arm, Feb. 16, 1853. Four hours after, he was 
seen by a young but very intelligent surgeon, wdio thought the humerus 
was broken just above the condyles. After eight weeks, the fact that 
it was a dislocation having become apparent, three surgeons, well known 
to me as men of large experience, attempted its reduction, aided by 
pulleys and chloroform. The patient was also bled, and nauseated with 
antimony. The efforts were protracted through many hours, and fre- 
quently varied. A second attempt made by these same gentlemen, a 
few days after, was equally unsuccessful. 

On the ninth week Mr. W. came to me, and I placed him at once 
in the Buffalo Hospital of the Sisters of Charity, where, assisted by my 
friend Prof. Moore, of Rochester, I renewed the attempt at reduction. 
The patient was placed under the influence of chloroform, and during 
a great portion of the time occupied the pulleys were in use. The 
elbow was pulled upon, twisted, flexed, and extended, until there 
seemed to be neither adhesions, nor ligaments, nor capsule, to prevent 
the reduction. We could move the joint in every direction, even later- 
ally, as w T ell as forwards and backwards. Still the bones would not 
return to their sockets. Section of the triceps seemed to be the only 
remaining expedient, but the injury already done to the joint was so 
great that we did not deem it prudent to prosecute the attempt any 
further. We had occupied two hours in the various procedures. Vio- 
lent inflammation supervened, but he was able to return home in about 
two weeks. Two years after, I learned that the arm still remained 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 631 



Fig. 2 



unreduced, and nearly anchylosed ; the whole limb was also much atro- 
phied and very weak. 

John Sharkie, set. 53, fell on the 4th of Aug. 1854. A botanic 
doctor, who saw him on the same day, and a regular physician, who 
saw him on the third day, thought he had broken his arm. About 
six weeks after this he came under the charge of an almshouse doctor, 
who "rebroke" it, supposing it to be a fracture; and two months later 
he " broke " it again ; but as the arm was not improved by these opera- 
tions, he finally urged the poor fellow to submit to amputation ; and it 
was in reference to this last proposition that Sharkie consulted me. I 
found the radius and ulna dislocated backwards and upwards one inch ; 
the arm perfectly straight and the elbow anchylosed ; no pronation or 
supination. I did not think it prudent to make any attempt to reduce 
it, but assured him that if let alone it would ultimately be quite useful 
in many ways, and that he should never think of having it cut off. 

In at least eight additional cases, according to my records, the acci- 
dent has been overlooked by reputable surgeons ; the injury having 
been supposed to be either a fracture or a mere contusion. Two of 
these had been examined by house surgeons at Bellevue. In one other 
case my house surgeon supposed he had reduced the dislocation, when 
he had not. 

In three or four instances, also, the accident has been overlooked by 
the patient himself, or by some empiric, no surgeon having been called 
to see the case until after the lapse of 
several days or weeks. 

In general, when the reduction has 
been effected promply, the patients 
have recovered the complete use of 
the elbow-joint within a few weeks ; 
but many exceptions have from time 
to time come under my notice. 

A lad eight years old was brought 
to me, whose arm had been dislo- 
cated six months before, and the re- 
duction of which had been accom- 
plished easily and promptly by Sir 
Astley Cooper's method. At this 
time the arm was bent to a right 
angle, and quite stiff at the elbow- 
joint. Four years later I learned 
that the stiffness still continued in a 
great measure, with only slight im- 
provement. 

Treatment — Sir Astley Cooper 
thus describes his own method of 
reducing this dislocation : " The pa- 
tient is made to sit upon a chair, 
and the surgeon, placing his knee 
on the inner side of the elbow-joint, 
in the bend of the arm, takes hold of the patient's wrist, and bends the 




Keduction with the knee in the bend of the 
elbow. 



632 DISLOCATIONS OF THE KADIUS AND ULNA. 

arm. At the same time he presses on the radius and ulna with his 
knee, so as to separate them from the os humeri, and thus the coro- 
noid process is thrown from the posterior fossa of the humerus; and 
whilst this pressure is supported by the knee, the arm is to be forcibly 
but slowly bent, and the reduction is soon effected." 

The same practice has been recommended by Erichsen, Gibson, 
Samuel Cooper, and others. The plan recommended by Dorsey is 
nearly identical with that just described, only that, instead of the knee, 
he advises that the surgeon " interlock his fingers in front of the arm, 
just above the elbow, and draw it backwards." 

On the other hand, Liston and Miller recommend, as a better mode 
of procedure, that the patient shall be seated upon a chair, and that 
the arm and forearm shall be pulled directly backwards, so as to relax 
as completely as possible the triceps muscle, while counter-extension is 
made against the scapula. 

Skey says : " Extension of the forearm should be made from the 
hand or wrist in a straight direction downwards, as if for the purpose 
of simply elongating the arm." 

Pirrie prefers that an assistant shall grasp the forearm near its mid- 
dle, instead of the wrist, and pull the arm straight forwards, while at 
the same moment the surgeon seizes upon the olecranon process with 
the fingers of one hand, and, placing the palm of the other against the 
front and upper part of the forearm, pulls forcibly backwards, so as to 
draw out the coronoid process from the olecranon fossa. Waterman 
recommends forced extension ; that is, bending the forearm forcibly 
back, as preliminary to flexion, with the view of lifting the coronoid 
process from the olecranon fossa. 1 

For myself, having generally practiced the method recommended by 
Sir Astley, and having usually succeeded in the first attempt and with 
the employment of only moderate force, I confess that my predilec- 
tions are in its favor ; yet I am not entirely certain but that an equal 
experience with either of the other modes recommended might have 
changed these convictions. The truth is, I think, that in recent cases 
very little force is generally requisite to accomplish the reduction, and 
that it is not very material which of these several modes we adopt ; 
but in case of a failure by one mode, we ought immediately and with- 
out hesitation to resort to another, as the following case of failure by 
flexion will illustrate: 

A lad, set. 11, fell in a gymnasium from a height of six feet, strik- 
ing probably upon his hand. I saw him within twenty minutes, and 
found the arm in the usual position. I attempted immediately to re- 
duce it by Sir Astley's method, but after a fair yet unsuccessful trial, 
I extended the forearm upon the arm until it was nearly straight, and 
then, with only moderate force, drew it promptly into place. 

If we still continue to encounter difficulties, the patient ought at 
once to be placed under the influence of an anaesthetic, and, if neces- 
sary, the pulleys should be employed. 

1 New Method of Reduction of the Elbow, by Thomas Waterman, M.D., Boston 
Med. and Surg. Journ., vol. iv, Nos. 12-13, new series, 1869. 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 633 

When the reduction is accomplished, which is indicated generally 
by the sudden slipping of the bones and by the restoration of the 
natural form to the elbow-joint, the surgeon, in order to confirm his 
opinion, must flex the forearm upon the arm to a right angle. If the 
bones are in place, and there is not much swelling, this can generally 
be done without causing much, if any, pain; but if it cannot be done, 
this fact furnishes presumptive evidence that the reduction is not 
effected. In one instance, however, of recent luxation, this rule has 
not held good. A girl, set. 10, fell from a tree upon her hand. I was 
in attendance within half an hour, and found the usual signs charac- 
terizing this accident. Reduction was accomplished readily by pulling 
at the hand moderately, with the forearm flexed, while my left hand 
pressed back the lower part of the humerus. After the reduction it 
was found impossible to flex the arm to a right angle without causing 
severe pain, and it became necessary, after placing it in a sling, to 
allow the hand to drop very low beside the body. A good deal of in- 
flammation followed ; but in a few weeks the arm was well, only that 
for a period of two years or more the elbow remained very tender. 

On the other hand, an omission to apply this rule has often led the 
surgeon to believe the reduction accomplished when it was not. This 
same thing has happened to myself, and as it is the only instance in 
which I have omitted to adopt this test, and the only one also in which 
I have left a bone unreduced which I believed to have been reduced, 
it will be proper to state the case and its results more fully. 

A lad, set. 11, fell from a fence on the 22d of December, 1858, and 
dislocated both bones backwards. I saw him within two hours from 
the occurrence of the accident. The elbow was already considerably 
swollen and quite tender, but the signs of dislocation were very mani- 
fest. Seizing the wrist with one hand, and placing my knee against 
the front and lower part of the humerus, I pulled steadily for some 
time, and with much more force than is usually necessary, until at 
length two distinct and successive snaps were felt, such as one often 
feels when the two bones resume their sockets. Relinquishing my 
grasp, it was observed by myself and the parents that the deformity 
had disappeared. The reduction seemed to be complete, and so I 
announced. I then requested the lad to permit me to bend the elbow, 
and place it in a sling, but this he peremptorily refused to do, and ran 
away from me, nor would any arguments or entreaties persuade him 
to allow me again to touch it. I reassured the parents and child, how- 
ever, that all was right, and left the house. During several successive 
days I saw the little patient, but although the arm remained swollen 
and very tender, I did not suspect the cause until the ninth day ; and 
on the tenth day, having placed him under the influence of chloroform, 
the reduction was easily and satisfactorily accomplished. The recovery 
has been slow. At the end of six weeks I found the motions of the 
elbow-joint not completely restored, and the forefinger was partially 
paralyzed ; but from this condition it has gradually recovered, and 
two months later the functions of the arm and hand were completely 
restored. 

The mistake in this instance was the more mortifying because I had 

41 



634 



DISLOCATIONS OF THE RADIUS AND ULNA. 



just seen a case in a lad only a little older, in which another surgeon 
had committed the same error, and after the lapse of twelve or four- 
teen days I had myself made the reduction ; and I was fully awake, 
therefore, to the possibility of the mistake. 

The circumstance of the diminution and apparent disappearance of 
the deformity, and the sensation of a double click, can only be explained 
by assuming that originally the coronoid process was resting in the 
olecranon fossa, and that by manipulation the bones had been removed 
nearer their sockets, yet not actually reduced. The swelling, also, 
rendered more difficult a diagnosis which, now, nothing but the flexion 
of the forearui could have determined positively. 

If much time has elapsed since the occurrence of the dislocation, the 
reduction is accomplished with difficulty, if, indeed, it can be reduced 
at all. There are many cases upon record, however, in which surgeons 
have been successful after the lapse of many weeks, or even months. 
Boyer thought it was not possible to effect the reduction after four or 
six weeks; but Capelletti, of Trieste, succeeded after seventy days; 1 
Sir Astley Cooper, at three months; 2 Malgaigne, after three months 
and twenty-one days. 3 Roux succeeded in a case of a young man 
tw T enty-two years of age, whose elbow had been dislocated five months. 4 
Blackman, of Cincinnati, informs me that he has reduced a lateral lux- 
ation after five months. Brainard, of Chicago, reduced a dislocated 
elbow in a boy of nineteen years, after five months and thirteen days. 
In this case the surgeon who had first seen the patient supposed that 
he had reduced the dislocation. 5 Gorre, Gerdy, and Drake succeeded 
in four cases after six months f I have succeeded at seven months; and 
Starch claims to have been successful after two years and one month. 7 
To which enumeration Denuce has added seventeen other examples, 
said to have been reduced at various periods, ranging from one month 
to one hundred and fourteen days. 8 

I have reduced quite a number of these old luxations, the five last 
of which will be briefly recorded. 

Thomas Robertson, set. 35, was admitted to Bellevue Hospital, De- 
cember 14th, 1864, with a simple dislocation of the radius and ulna 
backwards, which had existed thirty-one days, but which had not been 
up to this moment recognized by his surgeon. I reduced it before the 
class, by Sir Astley's method, the patient being under the influence of 
ether. Considerable force was required. 

J. G., set. 7, was brought to me in November, 1865, with a backward 
dislocation of the right radius and ulna, which had existed nine weeks. 
The arm was nearly straight and fixed. Having placed him under 
the influence of ether, assisted by Dr. Gurdon Buck, of this city, I 
proceeded to flex the arm slowly, and after a few seconds, and when 



1 Capelletti, Am. Journ. Med., vol. xix, from Annal. Univ. de Med. for Oct. 1835. 

2 Sir Astley Cooper, On Dislocations and Fractures, Amer ed., p. 388. 

3 Malgaigne, Amer. Journ. Med. Sci., vol. xxiii, p. 238, from Kevue Med., Dec. 
1837. 

4 Roux, Amer. Journ Med. Sci., vol. xvi, p. 526, from Archives Gen., Dec. 1834. 

5 Brainard, Illinois and Indiana Med. Journ., 1847. 

6 Memoire sur les luxations de coude, par Paul Denuce, Paris, 1854, pp. 86, 87. 

7 Denuce", op. cit., p. 87. s Op. cit. 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 635 

the elbow was bent about ten or fifteen degrees, the olecranon process 
separated at the line of epiphyseal union. In a few moments the 
reduction was completed, and the arm brought to an acute angle, but 
the olecranon had separated full half an inch. We were quite certain 
that the ulna was perfectly reduced, but the head of the radius did not 
seem to occupy its original position fully. Only moderate inflamma- 
tion ensued. Passive motion was soon commenced, and considerable 
motion of the joint was finally obtained. 

In April, 1869, a gentleman, set. 30, consulted me on account of a 
dislocation which had then existed ten weeks, and which had not been 
recognized by his surgeon. In attempting to reduce the dislocation 
I fractured the olecranon, and brought the ulna into position ; but I 
could not reduce the radius. Almost complete anchylosis of the elbow 
remains. 

In 1870, a man was brought to me whose elbow had been dislocated 
eight weeks. Under ether, I succeeded in reducing the dislocation, 
but fractured the olecranon process in doing so. He has recovered 
very good use of the joint. 

October 22, 1869, before the class of medical students at Bellevue, 
I reduced a dislocation in the case of a woman set. 37, which had ex- 
isted since the 10th of the preceding March, a little more than seven 
months. I have seen her often since; she has a somewhat limited but 
very useful motion of the joint. 

A few years since I assisted Dr. Sayre in reducing an old backward 
dislocation of these bones in the case of a boy. Other means having 
failed, while Dr. Sayre forcibly flexed the arm, I cut the triceps, after 
which the reduction was easily effected. Some months later the arm 
was nearly anchylosed at the elbow-joint, and it did not promise very 
well, so far as the usefulness of the member was concerned. 

Dr. W. F. ^Westmoreland, of Atlanta, Ga., has reported a case in 
which he succeeded readily in reducing a dislocation of the elbow 
backwards of five months' standing in a woman aged 22 years. The 
reduction was followed by great pain, a good deal of swelling, tempo- 
rary impairment of circulation in the radial artery, complete paralysis 
of the little finger, and partial paralysis of the middle and ring fingers. 
On the fourteenth day, at which period the history of the case closes, 
all these symptoms were rapidly disappearing. 1 

Nevertheless, the fact is in the main as stated by Boyer ; and if so 
many cases can be found in which surgeons have succeeded at a late 
period, they are not probably in the proportion of one to five as com- 
pared with the failures : but the failures have not received the same 
publicity. Xor, indeed, have all the severe accidents, such as violent 
inflammation, suppuration, gangrene, and even death, been faithfully- 
declared. Denuce says he has been able to trace out five or six ex- 
amples in which, although the arm was reduced, grave accidents re- 
sulted, and Yelpeau's patient actually died in consequence. 

Michaux, at the Hopital de Louvain, in 1841, in reducing an elbow 

1 Westmoreland, Atlanta Med. and Surg. Journ., May, 1866.. 



636 DISLOCATIONS OF THE RADIUS AND ULNA. 

dislocation, tore off the median nerve and brachial artery. Amputa- 
tion was made, and the life of the patient saved. 1 

Dixi Crosby, of New Hampshire, has treated two cases of ancient 
dislocation of the forearm backwards, by bending the elbow forcibly 
so as to break the olecranon process, after which the reduction was 
easily accomplished by extension. R. D. Mussey, of Cincinnati, has 
succeeded once in the same manner. 2 I have reported three similar 
examples. 

The dislocation being reduced, it may be a matter of prudence, 
sometimes, to apply a right-angled splint, first carefully padded, to the 
palmar surface of the arm and forearm ; remembering, however, that 
considerable swelling will soon occur, and that it ought not therefore 
to be bandaged to the limb very tightly. At least once a day it should 
be removed, and the arm examined ; and in very few cases can it be 
necessary or judicious to continue its application beyond one week. 
At the same time, if there is any especial tendency in the radius to 
become displaced backwards, owing to a rupture of its annular liga- 
ment, this must be prevented, if possible, by a compress and bandage. 
Some surgeons regard these precautions as necessary in all cases, but 
I have seldom employed any splint or bandage whatever, nor have I 
ever had reason to regret this omission. 

Finally, we are to place the arm in a sling, and adopt such measures 
as are calculated at first to reduce the inflammation ; and at a very 
early day we ought to begin to move the elbow-joint, in order to pre- 
vent anchylosis. 

I 2. Dislocations of the Radius and Ulna Outwards (to the Radial 

Side). 

The large majority of outward dislocations of the forearm are in- 
complete ; indeed, only nine examples of a complete dislocation have 
been collected by Denuce, including two seen by himself. 3 Malgaigne 
has since added two more ; Moliere, of Lyons, has reported one, 4 and 
Varick one, 5 making in all thirteen cases. Dr. Varick's case is re- 
ported as follows : 

" George Knight, set. 9 years, was thrown violently from a wagon 
while in rapid motion, striking on his head and back, with his left 
arm behind him in a state of flexion. He was brought to my office 
on the 31st of August, 1867, within ten minutes after the receipt of 
the injury, and, consequently, in the most favorable condition for ma- 
nipulation, no swelling of the soft parts having yet occurred. The fore- 
arm was in a state of semiflexion, supported by the hand of the oppo- 
site side, the ulna lying to the outer side of the external condyle, with 
slight posterior projection of the olecranon. The olecranon, coronoid 
process, and greater sigmoid cavity could be distinctly defined, and 

1 Debruyn, Des Luxations du Coude. These Inaug., Louvain, 1843, p. 77. 

2 Crosby, Mussey, Trans. Amer. Med. Assoc , vol. iii, p. 357. 

3 Denuce, Memoire sur les Luxationes des Coudes. Paris, 1854. 

4 Moliere, Monthly Abstract Med. Sci., vol. i, 1874, p. 269. 

5 Theodore R. Varick, M.D., Jersey City, N. J. ; Med. Rec, Nov. 1, 1867, p. 387. 



DISLOCATION OF RADIUS AND ULNA OUTWARDS. 637 



Fig. 279. 



the head of the radius, in its normal attachment, could be felt rotating 
subcutaneously on pronating and supinating the forearm. Free motion 
of the forearm in every direction was present, giving the impression of 
being attached to the arm solely by the soft parts. The projection of 
the internal condyle was out of all proportion to what is seen in cases 
of incomplete luxation. The trochlea, coronoid depression, and the 
olecranon depression were distinctly recognized. Complete dislocation 
of the ulna outwards was diagnosed, which diagnosis was corroborated 
by my friend, Dr. B. A. Watson, who was present and assisted in the 
reduction. 

" The patient was placed fully under the influence of ether, and 
moderate extension, combined with lateral pressure, effected the reduc- 
tion without difficulty. The subsequent treatment consisted of rest 
and cold irrigation for a few days, followed by 
passive motion of the parts, which resulted in per- 
fect recovery. The amount of inflammation which 
followed the injury was exceedingly slight, due 
unquestionably to the prompt reduction of the lux- 
ation." 

Incomplete dislocations must, therefore, in this 
case be regarded as typical ; but even these are by 
no means frequent. 

Causes. — A careful examination of a large num- 
ber of recorded examples, and of those which have 
come under my own eye, renders it certain that a 
majority of these accidents result from a blow re- 
ceived directly upon the inner side of the forearm 
or upon the outer side of the humerus, or from the 
action of two forces pressing in an opposite direc- 
tion. Of course those forces must act upon the 
bones somewhere in the neighborhood of the elbow- 
joint. Occasionally it has been produced by a fall 
upon the hand ; sometimes by a violent twist of 
the arm, as when the hand is caught in machinery; 
and in other cases it has been found consecutive 
upon a dislocation backwards, being produced in 
the attempts made to accomplish reduction of this 
latter form of dislocation. 

Pathology. — In most of the examples of simple incomplete outward 
luxation of the forearm, the great sigmoid cavity of the ulna still 
embraces the lower end of the humerus, but instead of reposing upon 
the trochlea, it is carried outwards half an inch or more, so as to rest 
its central crest upon the depression which separates the condyle from 
the trochlea. If the annular ligament remains unbroken, the radius 
is displaced in the same direction and to the same extent, its head 
resting against and directly below the epicondyle. 

Occasionally, however, where the violence has been greater, the cen- 
tral crest of the great sigmoid cavity rests fairly upon the condyle, 
or upon the articulating surface of the humerus where the head of 
the radius was formerly applied, and the dislocation approaches more 




Most frequent form of 
incomplete outward dis- 
location of the forearm. 



638 DISLOCATIONS OF THE RADIUS AND ULNA. 

nearly to the character of a complete luxation. At the same time, owing 
perhaps to the resistance afforded by the skin, or some of the liga- 
ments, the head of the radius may be thrown either forwards or back- 
wards, so as to be out of line with the ulna. Such a displacement 
generally implies a rupture of the annular ligament. 

We have now only to suppose the action of a more considerable 
force in the same direction to render the dislocation complete; in which 
case the upper end of the radius is sometimes thrown completely for- 
wards, and its head may even be found resting in front of the ulna, 
occasioning an extreme pronation of the forearm and hand. 

The anconeus and brachial is anticus are the only muscles in either 
of these dislocations whose fibres are generally much disturbed ; the 
biceps and triceps being only made to traverse the articulation a little 
more obliquely. 

Denuc6, Malgaigne, A. Cooper, and others have preferred to speak 
of the dislocation backwards and outwards as a distinct form or species 
of dislocation. I prefer to regard it as only a variety of the outward 
luxation, since it may, and no doubt often does, occur consecutively 
upon a simple incomplete outward dislocation ; and if the dislocation 
outward is complete, the bones of the forearm can scarcely fail to be 
drawn more or less upwards. Sometimes also it has been consecutive 
upon a simple backward dislocation, or upon unsuccessful attempts at 
reduction where the form of dislocation was originally backwards; yet, 
as it does not so naturally follow upon a complete backward dislocation 
as upon a complete outward luxation, I find sufficient reason for study- 
ing its mechanism in this place. 

The beak of the olecranon process not only, but a large portion of 
the body of this process, now lies above and behind the condyle; the 
brachialis anticus becomes more stretched, if not actually torn ; and the 
biceps is laid against the articulating surface of the humerus ; but the 
triceps becomes again relaxed, as in simple dislocation backwards and 
upwards. 

In all these dislocations the capsular ligaments are more or less ex- 
tensively torn, but the principal arteries and nerves do not generally 
suffer greatly, if at all. 

Symptoms. — The forearm is usually flexed to about the same angle 
at which we have found it in dislocations backwards; once I have 
found it nearly or quite straight; occasionally it is flexed to a right 
angle. In all the cases seen by me the forearm has been pronated, and 
the elbow-joint has been very immovable. The most striking diag- 
nostic sign, however, consists in the unnatural form of the elbow- 
joint, which is so remarkable as not to be easily misunderstood. The 
internal condyle of the humerus (epitrochlea) projects strongly to the 
inner side, leaving a deep depression below ; while upon the other 
side, the head of the radius, with its cup-like extremity, can be dis- 
tinctly felt, and made to rotate outside of its socket. The olecranon 
process, driven from its fossa, projects more or less posteriorly, and 
even the fossa itself may sometimes be plainly felt. 

A girl, twelve years old, had fallen upon the inside of her elbow, 
producing a dislocation outwards of the forearm. I saw her within 



DISLOCATION OF RADIUS AND ULNA OUTWARDS. 639 

half an hour. The forearm was bent upon the arm about fifteen de- 
grees, and immovably fixed. The head of the radius could be dis- 
tinctly felt external to and a little in front of the outer condyle, while 
the olecranon process of the ulna, which rested upon the back and 
outer surface of the humerus, was less distinctly felt than in the oppo- 
site arm. The inner condyle projected sharply to the inside, and the 
olecranon fossa was plainly felt with the fingers. The child was suf- 
fering very little pain. 

Seizing the wrist with my right hand and the lower end of the 
humerus with the left, and making moderate extension in these oppo- 
site directions, the bones easily, and after only a moment's effort, re- 
sumed their places. Her recovery was rapid and complete. 

James O'Neil, set. 16, was admitted to Bellevue Hospital in Dec. 
1865, with a dislocation caused by the kick of a horse, the blow hav- 
ing been received on the ulnar side of the forearm near the elbow- 
joint. When he came under my notice the dislocation had existed 
three weeks. I found the head of the radius reposing upon the radial 
and posterior side of the humerus. The ulna was displaced one inch 
to the radial side. The forearm was not at all, or but very slightly, 
flexed upon the arm. The natural deflection of the forearm to the 
radial side was a little exaggerated : forearm pronated : elbow-joint 
admitting of a little motion ; but motion caused great pain. 

This patient was not in my service, and I have not learned the 
result of the attempt at reduction. 

If the dislocation is complete, the position of the arm is usually the 
same, but the pronation of the hand is greater, and the projection of 
the inner condyle more striking. 

If now the bones, by a continuance of the original force, or by the 
action of the triceps, are drawn upwards also, the arm becomes a little 
more flexed, and the olecranon process more prominent, while the 
length of the whole limb is sensibly diminished. 

Prognosis. — In recent cases of incomplete outward luxation, and 
where no complications exist, the reduction is generally easily effected ; 
and M. Thierry claims to have reduced an outward and backward 
luxation after eight months. A patient of whom Debruyn has spoken 
was not so fortunate. On the 16th of April, 1841, a lad, set. 18, fell 
upon the palm of his hand and dislocated both bones outwards and 
backwards; on the following morning a surgeon attempted to reduce 
the dislocation, and the attempt was repeated on the next day by 
another surgeon ; but on the day following this last attempt, gangrene 
ensued in consequence of the great violence employed by the surgeons, 
and, although the limb was amputated, the patient died. The autopsy 
showed that both the brachial artery and the median nerve were torn 
asunder, and that the tendons of the biceps and the brachial is anticus 
were slipped behind the outer condyle, probably having been thrown 
into this position during the violent twistings to which the arm had 
been subjected. 1 

1 Denuce, op. cit., p. 103. 



640 DISLOCATIONS OF THE RADIUS AND ULNA. 

I have seen three examples of dislocations upwards and outwards 
which the medical attendants had failed to reduce. The first was in 
the case of a lad, William Kinkaid, fourteen years old, who had fallen 
from a wagon and struck upon the palm of his left hand. The sur- 
geon who was immediately called made extension, and supposed that the 
reduction was accomplished. The lad was brought to me a few months 
after the accident. The arm was slightly flexed, and neither prone 
nor supine. There existed only a slight motion at the elbow-joint. I 
did not think it worth while to make any attempt at reduction. Several 
years after this, in the month of February, 1859, I had an opportunity 
of examining the arm again. He had now recovered considerable 
motion in the joint, but he could not tie his cravat. Pronation and 
supination were perfect. 

In the second example, a lady, set. 33, had fallen upon the inside of 
her elbow, and reduction not having been accomplished, I found her, 
nine weeks after the accident, with scarcely any motion at the elbow- 
joint, and complaining of a numbness in the forearm and hand. 

The third instance of unreduced dislocation I will relate more at 
length. 

Francis Banfield, aged twenty-two years, a resident of Alleghany 
County, N.Y., on the 31st of September, 1857, fell from the sweep of a 
threshing-machine to the ground, a distance of about five feet, striking 
upon the palm of his hand, his arm being extended in front of him. 
On rising, he found his arm forcibly flexed and abducted. He straight- 
ened it without difficulty, and it assumed the position it now occupies. 
A physician was called and saw the patient an hour and a half after 
the accident, who pronounced it a case of dislocation of the radius and 
ulna, and made efforts at reduction, which he continued from 8J a.m. 
until 2 p.m., a period of five and a half hours, to no purpose, when he 
abandoned the attempt. During the attempt at reduction, the exten- 
sion was made at times with the arm flexed, and at others extended. 
At 9 p.m. another physician was called, who made efforts at reduction 
until 3 a.m., upwards of six hours, at which time he also abandoned 
the attempt. On the third day another physician, the patient being 
under the influence of ether, made efforts at reduction for twenty 
minutes, when he pronounced it in place, and applied a bandage. 
From the patient's account, the arm was swollen to such an extent as 
to render this point difficult to determine. On the fifth day the first 
physician was called, and believing that he discovered a grating, pro- 
nounced it a fracture of the external condyle. 

Four months after the accident, when the patient applied to me, the 
limb presented the following appearances: "The forearm extended 
upon the arm ; looking at the limb along its radial margin, we notice 
a gentle outward inclination of the forearm from the elbow down, but 
by manipulation this may be greatly increased ; the power of prona- 
tion and supination is not affected ; the inner condyle projects an inch 
to the ulnar side; the head of the radius, completely removed from its 
socket, projects to an equal extent on the radial side. The top of 
the olecranon process is an inch higher than the top of the inner con- 



DISLOCATION OF RADIUS AND ULNA INWARDS. 641 

dyle, so that the radius and ulna are carried upwards as well as out- 
wards." 

I believe that the external condyle was not broken, as in that case 
the arm would be permanently deflected outwards to a much greater 
extent. For, although this arm may be deflected outwards by the sur- 
geon to an angle of 135°, still the degree of mobility which exists 
would be adverse to the supposition of its being a fracture of the exter- 
nal condyle. The condyles also can be plainly felt in their natural 
situations, which would not be the case if a fracture of the external 
condyle existed. The patient was advised not to submit to any further 
attempts at reduction. 

The following will serve as an illustration of a recent accident of 
this character : 

John Collins, of Buffalo, set. 8, fell while wrestling, his companion 
falling upon his arm. I found the forearm slightly flexed, pronated, 
and both radius and ulna thrown over to the radial side and carried 
upwards. Pressing firmly upon the radius from the outside, the bones 
assumed suddenly the position of a backward and upward dislocation, 
from which position they were readily reduced to their original sockets 
by simple extension. 

Treatment. — In relation to the treatment of these accidents we have 
little to add to what has already been said of the treatment of disloca- 
tions backwards. The reduction, if effected at all, has generally been 
accomplished by moderate extension, or by extension combined with 
lateral pressure. If the head of the radius is in front of the humerus, 
or of the ulna, the hand should be firs* supined, and then the extension 
should be applied. In some cases the reduction has been effected by 
placing the knee in the bend of the elbow and flexing the forearm, 
while the surgeon was making extension from the hand. 

\ 3. Dislocation of the Radius and Ulna Inwards (to the Ulnar Side). 

This form of dislocation is much more rare than the dislocation out- 
wards, a fact wmich may perhaps find a sufficient explanation in the 
peculiar form of the trochlea, the inner half of which rises much higher 
than the outer, forming thus an elevated inclined plane, over which 
the articulating surface of the ulna must rise before the dislocation can 
occur. 

Like the opposite dislocation, the typical form of the accident is that 
in which the displacement is incomplete; indeed, no example of a com- 
plete inward dislocation has, we think, been yet recorded. 

Causes. — A fall upon the hand or forearm, a blow upon the radial 
side of the forearm near its upper end, or upon the ulnar side of the 
arm near its lower end, a violent wrenching of the limb, are among the 
causes which may occasion this dislocation. 

Pathology. — The ridge which divides antero-posteriorly the greater 
sigmoid cavity of the ulna, having been driven over the elevated 
inner margin of the trochlea, falls down upon the epitrochlea, so as, in 
some sense, to embrace it instead of the trochlea; while the head of the 



642 



DISLOCATIONS OF THE RADIUS AND ULNA. 



Fig. 280. 




radius passes inwards also, and is made to occupy the trochlea, from 
which the ulna has escaped. Generally the head of the radius is found 
in the same line with the ulna (Fig. 280), but 
it may suffer a luxation and be found a little 
in advance of the ulna, or possibly a little in 
the rear. 

I choose also to regard the dislocation in- 
wards and upwards as only a variety of the 
dislocation inwards ; in which form of the ac- 
cident the coronoid process of the ulna is thrust 
upwards above the epicondyle, and the head 
of the radius occupies the olecranon fossa, or 
rests upon the back of the humerus somewhere 
in this vicinity. 

In addition to the injury suffered by the 
ligaments and muscles, the ulnar nerve in both 
varieties of inward dislocation is peculiarly 
liable to contusion, in consequence of its being 
crushed between the olecranon process and the 
epitrochlea. 

Symptoms. — If the dislocation is only in- 
wards, the olecranon process can be felt pro- 
jecting upon the inner side, and completely 
concealing the epicondyle ; while the head of 
the radius, having abandoned its socket, may 
be felt indistinctly in the bend of the arm. 
The external condyle (epicondyle) is remarka- 
bly prominent. The forearm is generally more or less flexed, and the 
hand forcibly pronated. The natural outward deflexion of the forearm is 
also lost, or it may be even inclined slightly inwards. This phenomenon 
is explained by the position of the epicondyle, upon which the greater 
sigmoid cavity now rests, allowing the ulna to overlap a little upon the 
humerus; rendering the forearm actually somewhat shorter along its 
ulnar margin, although the head of the radius may still occupy the 
summit of the trochlea. 

If the bones are displaced upwards as well as inwards, a considerable 
shortening is declared, and the head of the radius may now be felt 
behind the trochlea, or over the olecranon fossa. In three of the four 
examples seen by Malgaigne, all of them ancient, the forearm was in 
a state of supination. Other surgeons have met with cases in which 
the forearm was supine, but they must be considered as exceptions to 
the rule. 

The following example of this dislocation, unreduced after the lapse 
of fourteen years, is reported to me by Dr. T. H. Squier, of Elmira, 
N. Y. : Thomas Cook, now in his nineteenth year, was four years and 
ten months old when he fell from a pile of boards about as high as a 
man's shoulder. According to his statement, given at the time, his 
right arm caught between the boards, and, in falling, he turned a som- 
ersault. The mother, to whom the child immediately ran, grasped 
his arm which he said was broken, and found that it would roll and 



Most frequent form of incom- 
plete inward dislocation of the 
forearm. 



DISLOCATION OF RADIUS AND ULNA INWARDS. 643 

turn in various ways. "When the surgeon arrived, three hours after- 
wards, the arm was very much swollen and the accident was supposed 
to be a fracture. At present flexion and extension are perfect. The 
forearm has an inward deflection of a hand's breadth more than the 
other. The power of pronation is complete, but the forearm and hand 
cannot be supinated entirely. The external condyle is very prominent, 
but the internal is almost hid by the olecranon, which projects inwards 
nearly as far as the point of the epicondyle. The finger can be laid in 
the olecranon fossa behind, and all the back part of the trochlea can be 
distinctly traced. By flexing the forearm slowly, as it approaches a 
right angle, the tendon of the triceps may be felt, lodged, as it were, 
on the back part of the point of the epicondyle; and by continuing the 
flexion, the tendon suddenly slips over this point and places itself on 
the anterior aspect of the arm. When the forearm is fully flexed, the 
tendon is advanced full three-quarters of an inch in front of the epicon- 
dyle. The arm is very serviceable, but invariably pains him after a 
hard day's work. 

Prognosis. — Malgaigne was unable to reduce the dislocation in a 
recent case of incomplete internal dislocation, which came under his 
own notice. Triquet succeeded in a child seven years old, on the 
fifteenth day, after many trials ; but the movements of the elbow-joint 
were never restored. Dubruyn succeeded on the fifth day, but not 
without difficulty ; the case reported by Sqnier was mistaken for a frac- 
ture, and no attempt at reduction was made ; and in the only remain- 
ing example which has been put upon record, the precise character of 
the accident having been determined by Velpeau, reduction was easily 
accomplished, and on the eighth day the patient was dismissed. 1 

Of the four examples of inwards and backwards luxation seen by 
Malgaigne, not one was ever reduced; but as the history of them all is 
not complete, it is by no means to be inferred that reduction could not 
have been easily accomplished, at least in some of them, at the first. 
Nor, with such imperfect details before us, can we understand fully 
what complications may have existed, such as would perhaps render 
these exceptional, rather than illustrative examples. 

One of these patients had a completely anchylosed elbow at the end 
of two years, but pronation and supination were preserved. In the case 
of another, however, even flexion and extension were as perfect as in 
the normal condition. 

Treatment. — The indications of treatment are the same as in disloca- 
tions outwards, with only such slight modifications as the judgment of 
every surgeon must naturally suggest. I prefer to employ by way of 
illustration the example diagnosticated by Velpeau. 

On the 10th of May, 1848, Alexandrine Guyot, set. 22, entered the 
Hospital of La Charite with an incomplete inward dislocation of the 
forearm, which had just occurred. The hand and forearm were in a 
state of forced pronation, half-flexed and the whole limb from the elbow 
downwards was deflected inwards. There were present also all the 

1 Denuce, op. cit., pp. 154-156. 



644 DISLOCATIONS OF THE RADIUS AND ULNA. 

other usual signs of this dislocation, and Velpeau had no doubt as to 
its true character. 

In order to accomplish reduction, one assistant made counter-exten- 
sion upon the arm, while a second made direct extension upon the 
forearm. At first the tractions were made in the direction of the fore- 
arm (flexed and prone), but gradually the arm Avas straightened and 
supinated. Then the surgeon, seizing with one hand the superior ex- 
tremity of the forearm, and with the other the inferior extremity of 
the arm, acted forcibly upon the two portions in opposite directions, 
and immediately the reduction was effected with a noise. 1 

\ 4. Dislocation of the Radius and Ulna Forwards. 

Sir Astley Cooper, Yidal (de Cassis), and others have denied that 
this dislocation was possible without a fracture of the olecranon pro- 
cess ; but Monin, Prior, Velpeau, Canton, 2 and Denuce have each re- 
ported one example, so that its existence may now be considered as 

Fig. 281. 



E. Canton's case of dislocation of the radius aud ulna forwards. 

established. Nevertheless, it is only as a result of very violent and 
extraordinary accidents, by which the forearm is forcibly flexed, or 
greatly extended, or twisted, or in some other unusual and indirect 
way the olecranon is placed in front of the humerus. 

The following is a summary of the facts in Velpeau's case. Alex- 
andrine Carelli, set. 23, was knocked down by a carriage, on the first 

1 Denuce, op. cit., p. 155. 2 Dub. Quart. Journ. of Med. Sci., Aug. 1860. 



DISLOCATIONS OF THE WRIST. 645 

of July, 1848, the wheel passing over the right arm. The arm was 
found in a right-angled position, and it could neither be flexed nor 
extended ; the forearm was strongly supinated ; the projecting angle 
usually made by the olecranon process was replaced by the irregular 
extremity of the humerus ; the forearm was shortened upon the arm ; 
the head of the radius resting in the coronoid fossa, and the olecranon 
process being also carried upwards and a little outwards. Reduction 
was easily accomplished, and the patient left on the nineteenth day, 
with only a slight remaining stiffness in the joint. 1 

A case is reported to have come under the observation of Mr. J. W. 
Langmore, house surgeon at the University College Hospital, London. 
It was occasioned by a fall upon the elbow. The reduction of the 
ulna was easily accomplished by placing the knee in the bend of the 
elbow and flexing the arm. The radius was then reduced by pressure 
and extension. 2 

Chapel has reported a case of dislocation forwards and outwards, 
which he readily reduced soon after it occurred, while Colson, Leva, 
and Guyot have each reported one example of .s'«6-luxation forwards, 
in which the extremity of the olecranon process has been found resting 
upon the extremity of the humeral trochlea. 3 

Treatment. — If the dislocation is complete, and the forearm is short- 
ened and flexed upon the arm, the reduction should be first attempted 
by violent flexion, or by flexion combined with extension from the 
wrist, and counter-extension from the lower portion of the humerus. 
If the dislocation is incomplete, and the forearm is extended upon the 
arm, the reduction may be readily accomplished by extension alone, or 
bv moderate flexion. 



CHAPTER X. 

DISLOCATIONS OF THE WKIST (RADIO-CARPAL). 

Regarded as an accident of not unusual occurrence by Hippocrates, 
J. L. Petit, Duverney, Boyer, and by most if not all of the older 
writers, its frequency began to be questioned by Pouteau, and finally 
its existence was almost absolutely denied by Dupuytren, who remarks : 
"I have for a long time publicly taught that fractures of the carpal 
end of the radius are extremely common ; that I had always found 
these supposed dislocations of the wrist turn out to be fractures ; and 
that, in spite of all which has been said upon the subject, I have never 
met with, or heard of, one single well-authenticated and convincing 
case of the dislocation in question." Dupuytren subsequently declared 
that he would not positively deny the possibility of the accident, yet 

1 Denuce, op cit., p. 110. 

2 New York Med. Record, March 1, 1867, from the London Lancet. 

3 Denuce, p. 120. 



646 DISLOCATIONS OF THE WRIST. 

that " it must at least be admitted that the accident is an extremely 
rare one." Wishing to explain this infrequency, he says: "In exam- 
ining the structure of the soft parts, one cannot fail to perceive that it is 
not the ligaments which prevent the displacement of the articular sur- 
face forwards, but that this effect is especially due to the multitude of 
flexor tendons, deprived as they are at this point of all the fleshy parts, 
and reduced to the simple fibrous tissue which composes them. These 
tendons are bound together beneath the anterior annular ligament of 
the wrist, and thus offer so efficient a resistance that severe falls are 
insufficient to tear them through ; the hand is forced into a state of 
extreme extension, and the tendons are firmly applied on the anterior 
part of the radio-carpal articulation. If the extension is still further 
augmented, the wrist-joint is yet more closely clasped by these parts, 
and their power of resistance is incalculable ; I am convinced that a 
force equivalent to one thousand pounds weight would be inadequate 
to overcome it ; and the known power of the tendo Achillis is suffi- 
cient to prove that this computation is not exaggerated. 

" The risk of dislocation backwards by a fall on the dorsal surface 
of the hand is equally precluded by the tendons of the extensor mus- 
cles. Their arrangement and relations at the back of the joint are 
similar ; it is true, they are not quite so strong ; but we must admit 
that their power of resistance is very considerable, when w r e take into 
consideration how they are inclosed in sheaths as they cross beneath 
the posterior annular ligament of the wrist. I have not alluded to the 
ulna, for it has really little or nothing to do with these movements, as 
it does not articulate (directly) with the hand. 

"To sum up, then, the extreme rarity of dislocation forwards or 
backwards is owing to the obstacles opposed by the flexor or extensor 
tendons." 

The opinion of such a writer as Dupuytren, whose experience was 
very great, and who described only what he had seen, is always en- 
titled to profound respect ; yet it has been the practice of nearly all 
who have made any reference to his opinions in this matter to speak 
of them lightly, and not a few have falsely represented him as saying 
that such a dislocation was " impossible." The fact is, that surgeons 
do still constantly mistake fractures of the lower end of the radius 
for dislocations, as my own personal observation can attest; and not- 
withstanding examples have been reported by Rene, Marjorlin, Padieu, 
Cruveilhier,Voillemier, Boinot, Malgaigne,Scoutetten,Bransby Cooper, 
Fergusson, W. Parker, and others, yet the whole number of cases for 
which the distinction is claimed is, to this day, so inconsiderable as 
only to establish the value and accuracy of Dupuytren's opinion that 
the " accident is an extremely rare one." But it is, perhaps, most re- 
markable, that while very few of these supposed examples have been 
verified by an autopsy, in every instance in which the autopsy has been 
made, the dislocation has been found to be complicated with a fracture, 
generally of the lower extremity of the radius or of the styloid apophy- 
sis of the ulna. 

The existence of a. complication, however, does not render the acci- 
dent any the less a dislocation, although it may render the diagnosis 



DISLOCATIONS OF THE WRIST. 647 

more difficult, and modify somewhat the indications of treatment. A 
knowledge of the fact, also, that such complications have always been 
observed in the autopsy, may leave us in doubt as to what is the nat- 
ural history of a simple, uncomplicated dislocation, if, indeed, it does 
not warrant a suspicion that such a case never occurs. We shall, 
nevertheless, after a careful analysis of the cases as they have been 
reported, and by a consideration of the anatomy of this articulation, 
be able to determine with some degree of accuracy, perhaps, what are, 
or what ought to be, the usual causes, signs, treatment, etc., of these 
accidents. 

Partial luxations have also been frequently described by surgeons. 
I have never met with an example, but the following case, related to 
me by the patient himself, I believe to have been a case in point. 

Lewis C, of Buffalo, set. 18, by a fall upon his hand, broke the left 
forearm below the middle, and at the same time, as he affirms, partially 
dislocated the carpal bones backwards. Dr. Spaulding, of Williams- 
ville, N. Y., took charge of the limb, and pronounced it a fracture, 
with partial dislocation, and for more than a year after the accident 
the bones had a tendency to become displaced in the same direction. 
Whenever he attempted to lift even the w T eight of half a pound, with 
his hand supinated and his forearm extended horizontally, the lower 
end of the radius would spring suddenly forwards, and all power in 
the arm would be lost. When this happened, as it did quite often, he 
always reduced the bones himself, by simply pushing upon them in the 
direction of the articulation. 

Fourteen years after the accident, I examined the arm and found it 
in all respects perfect, except that the forearm w T as shortened about 
one-third of an inch, which shortening w T as due, no doubt, to the over- 
lapping of the broken bones. 

(I am unable to verify the accuracy of the statements made in the 
following paragraph ; but as there seems to be no reason why they 
should not be accepted, it will be proper to give them a place in this 
treatise. 

" According to Francis L. Parker, M.D., Professor of Anatomy in 
the Medical College of South Carolina (Trans. S. C. Med. Assoc), there 
are thirty-three cases of so-called dislocations of the wrist-joint on 
record (omitting the cases of W. Parker and Rene), including his own, 
viz., case of dislocation of the wrist-joint backwards. Of these, twenty- 
three are said to have been luxated backwards and ten forwards, and 
of this entire number only seven, five backwards and two forwards, 
are free from all objection. Of the twenty-six cases of doubtful or 
unsatisfactory dislocations, sixteen were complicated with fracture of 
one of the bones or processes connected w 7 ith the joint ; three were com- 
pound, three w r ere incomplete, tw r o were arthritic or pathological speci- 
mens, and two were objected to from other causes. Of the thirty-three 
so-called dislocations, the sex is recorded here in fourteen instances; of 
these eleven were males and three were females. Of the seven cases 
classed as genuine ones, one post-mortem was made (case of M. Malle), 
which confirmed the diagnosis ; in six remaining cases the patients 
regained the use of the limb in a very short time, without a tendency 



648 DISLOCATIONS OF THE WRIST. 

to displacement or deformity. Of these seven cases accepted as genuine, 
two backward dislocations were produced, the force of the fall being 
received, in one instance, on the dorsum of the hand (Hamilton's); in 
the other upon the palmar surface (Parker's); in M. Malle's case, a 
forward displacement, the presumption is that the patient fell on the 
palm of his hand, but this is not definitely stated ; and in the four re- 
maining cases this point is not specified. He lays down the following 
practical conclusions, which may be derived therefrom : 1st. The wrist- 
joint may be dislocated backwards or forwards without fracture or a 
rupture of the integuments; both are extremely rare; the backward 
displacement is the most frequent. 2d. Cases of so-called dislocation 
of the wrist may be associated with fracture of the radius aud ulna, or 
with either of these bones separately, with both styloid processes, or 
either of them, or with fracture of the articulating surface of the radius; 
no instance has been recorded of a dislocation of this joint complicated 
with fracture of the carpal bones. 3d. Dislocation of the wrist back- 
wards or forwards may be complicated with rupture of the integuments 
anteriorly or posteriorly, or laterally, with or without fracture of the 
styloid processes." 1 ) 

I 1. Dislocations of the Carpal Bones Backwards. 

Causes. — The same casualty, namely, a fall upon the palm of the 
hand, which, as we have elsewhere noticed, produces frequently a frac- 
ture of the lower end of the radius, occasionally a dislocation of the 
radius and ulna backwards, at the elbow-joint, may also, it is believed, 
occasion sometimes a dislocation of the carpal bones backwards. In 
several of the cases reported, this cause has been assigned ; but in the 
only example of simple dislocation which has ever come under my 
notice, and which I have every reason to believe was a simple dislo- 
cation unaccompanied with a fracture, the carpal bones were thrown 
back by a fall upon the back of the hand. The following is a brief 
account of the case : 

The Rev. Stephen Porter, of Geneva, N. Y., set. 75, while walking 
with his son after dark, and holding in his right hand a satchel, slipped 
and fell. In the effort to save himself, and still retaining his grasp 
upon the satchel, his right hand struck the sidewalk flexed, and in 
such a way as that the whole force of the fall was received upon the 
back of the hand and wrist, thus throwing the hand into a state of 
extreme flexion. In less than twenty minutes he was at my house. 
No swelling had yet occurred, and the moment I looked at the wrist 
I said to him, " You have broken your arm;" so much did it resemble 
a fracture of the lower end of the radius. A further examination led 
me to a different conclusion. The palmar surface of the wrist pre- 
sented an abrupt rising near the radio-carpal articulation, the summit 
of which was on the same plane and continuous with the bones of the 
forearm, and a corresponding elevation existed upon the dorsal surface 
terminating in the carpal bones and hand ; the hand was slightly 

1 F. L. Parker, Med. Ree., Nov. 1, 1871. 



DISLOCATIONS OF THE CARPAL BONES BACKWARDS. 649 

inclined backwards, but the fingers were moderately flexed upon the 
palm. To this extent the accident bore the features of a fracture of 
the radius; but the hand did not fall to the radial side; the projec- 
tions upon the palmar and dorsal surfaces were more abrupt than I 
had ever seen in a case of fracture, and which, if it were a fracture, 
would imply that the broken extremities had been driven off from 
each other completely ; the most salient angles of these projections 
were abrupt, but not sharp or ragged ; the styloid apophyses could be 
distinctly felt, and I was not only able to determine that they were 
not broken, but, by observing their relations to the palmar and dorsal 
eminences, it was easy to see that these latter corresponded to the 
situation of the articulation. 

In addition to these evidences that I had to deal with a dislocation, 
and not a fracture, we had the testimony furnished by the reduction, 
which was not made, however, until by every possible means the diag- 
nosis was definitely settled. Seizing the hand of the gentleman with 
my own hand, palm to palm, and making moderate but steady exten- 
sion in a straight line, the bones suddenly resumed their places with 
the usual sensation or sound accompanying reductions. There was no 
grating, or chafing, or crushing, nor was the reduction accomplished 
gradually, but suddenly. To test still further the accuracy of the 
diagnosis, I now pressed forcibly upon the wrist from before back, but 
without producing any degree of displacement, nor could any crepitus 
still be detected. No splint was applied, and on the following morn- 
ing Mr. Porter preached from one of the pulpits in the city, only re- 
taining his arm in a sling. 

Sixteen months after the accident, September 15, 1858, this gentle- 
man again called upon me, and I found the arm perfect in all respects, 

Fig. 282. 




Dislocation of the carpal bones backwards. (From Fergusson.) 

except that it was not quite as strong as before ; the lower extremity 
of the ulna was preternatural ly movable, and occasionally he felt a 
sudden slipping in the radio-carpal articulation. 

Pathological Anatomy. — In the examples of compound or compli- 
cated dislocations, which have been exposed by dissections, the pos- 
terior and lateral ligaments have been found extensively torn, as also 

42 



650 DISLOCATIONS OF THE WRIST. 

frequently the anterior ligament, with or without separation of the 
radial or ulnar apophyses; the extensor muscles torn up from the lower 
part of the forearm and displaced ; the first row of the carpal bones 
lying underneath the tendons, and upon the bones of the forearm, 
sometimes having been carried directly upwards, sometimes upwards 
and a little inwards, and at other times upwards and outwards ; the 
arteries and nerves have occasionally escaped serious injury, but more 
often they have been displaced, bruised, or torn asunder. 

Such are, briefly, the pathological circumstances which may be sup- 
posed to exist, also, in a lesser or greater degree, in nearly all cases of 
simple dislocations. 

In compound dislocations, however, the muscles, or rather the ten- 
dons, are twisted, torn, and thrust aside, producing very extensive 
lesions among the deeper structures of the forearm and hand before 
the integuments can be made to yield. 

On the 2d of May, 1852, Silas Usher, set. 54, had his right arm 
caught between the bumpers of two cars, bruising the hand and dislo- 
cating the carpal bones backwards, the radius and ulna being thrown 
forwards and pushed completely through the skin into the palm of the 
hand. Most of the flexor tendons had been merely thrust aside, but 
one or two were torn asunder ; the median nerve was torn off, but the 
radial and ulnar nerves were apparently uninjured, and there was no 
fracture. The patient being a temperate man, in perfect health, and 
the bones having been easily replaced by moderate extension, it was 
determined to make an effort to save the arm. The limb was therefore 
laid on a carefully padded splint, and cool water lotions diligently 
applied. Phlegmonous erysipelas began to develop itself on the third 
day ; and on the ninth, gangrene having attacked the limb, I ampu- 
tated a little above the middle of the humerus. On the fourteenth 
day haemorrhage occurred suddenly from the stump, and when I reached 
him he was pulseless and dying. 

The result demonstrated the error of the attempt to save the limb 
without resection of the lower ends of the bones of the forearm. 

Symptoms. — The usual signs have already been sufficiently stated 
in the example which we have given. The most important diagnostic 

marks are found in the abruptness 
fig. 283. of the angles formed by the pro- 

jecting bones; the relation of these 
prominences to the styloid apophy- 
ses ; in the total absence of crepi- 
tus; and in the reduction, which is 
accomplished easily, suddenly, and 
with a characteristic sensation. If 
Dislocation of the carpal bones backwards. a fracture complicates the accident, 

crepitus may also be present. It 
should be remembered, moreover, that when the styloid process of the 
radius is broken, if the hand is moved backwards and forwards this 
process will move also, which might lead to the supposition that the 
radius was broken higher up, and that it was not a dislocation at all. 
Prognosis. — In compound dislocations the prognosis is exceedingly 




DISLOCATIONS OF THE CARPAL BONES FORWARDS. 651 

grave, unless the surgeon determines to resort to amputation, or, what 
is generally much preferable, to resection. In dislocations complicated 
with fracture of the posterior edge of the articulating surface of the 
radius (" Barton's fracture " *), some difficulty may be experienced in 
retaining the bones in place; but when this fracture does not exist, the 
posterior margin of the articulation, considerably elevated above its 
anterior margin, constitutes a sufficient protection against a reluxation 
in that direction. In all cases, also complicated with fracture, even of 
an apophysis, intense inflammation and swelling are likely to follow, 
and the danger of a permanent anchylosis is greatly increased. 

Treatment. — Extension in a straight line has generally been found 
sufficient to accomplish the reduction ; to which may be added a slight 
rocking or lateral motion, if necessary. 

The reduction may be effected also by pressing the hand backwards, 
while the surgeon pushes the carpus downwards from behind and 
above, in the direction of the articulation; 

Unless a tendency to displacement exists, no splints or bandages of 
any kind ought to be applied, but it should be treated by rest and cool 
water lotions until all danger from inflammation has passed. 

\ 2. Dislocations of the Carpal Bones Forwards. 

The causes, mechanism, symptoms, pathology, treatment, etc., of this 
accident resemble in so many points those of the preceding dislocation, 
with only the differences neces- 
sarily due to a change in the 
direction of the bones, that I 
find it not worth while to do 
more than to relate one single 
example, contained in Bransby 
Cooper's edition of Sir Astley's 
work on Fractures and Disloca- 
tions. The case did not come 
under the observation of Mr. 
Cooper himself, but was related 
to him by Mr. Haydon, a sur- 
geon residing in London. It 
is especially interesting as fur- 
nishing an example of a disloca- 

?, , . r , Dislocation of the carpal bones forwards. 

tion oi both wrists at the same 

moment, and from similar causes, but in opposite directions. 

A lad, aged about thirteen years, was thrown violently from a horse 
on the 11th of June, 1840, striking upon the palms of both hands and 
upon his forehead. The left carpus was found to be dislocated back- 
wards, the radius lying in front and upon the scaphoides and trapezium. 
The right carpus was dislocated forwards, the radius and ulna project- 
ing posteriorly, and the bones of the carpus forming an " irregular 
knotty tumor terminating abruptly" anteriorly. 

1 Philadelphia Medical Examiner, 1838. 




652 DISLOCATIONS OF THE LOWER END OF ULNA. 

A very careful examination was made to determine what parts came 
in contact with the resisting force, but although the palms of both 
hands were extensively bruised, there was not the slightest bruise on 

the back of either hand. Nor 
FlG - 285 - were the gentlemen present able 

^-- — v. ^^_^ to find any evidence whatever 

/!^ " ' that the dislocation was accom- 

panied with a fracture. " More- 
over," says Mr. Haydon, " we 
were strengthened in our opin- 

Dislocation of the carpal bones forwards. ion that tills WaS a Case of dis- 

location, unattended with any 
fracture, because the dislocations appeared so perfect; the two tumors 
in each member so distinct; the reduction so complete; the strength of 
the parts after reduction so great ; and lastly, by the very trifling pain 
felt after reduction, for within an hour after, the patient could rotate 
the hand, and supinate it when pronated — this could not, we believe, 
have been done had there existed a fracture." 



\^^ _____ over," says Mr. Haydon, " 

^w 3 -^ were strengthened in our or 



CHAPTER XL 



DISLOCATIONS OF THE LOWER END OF THE ULNA (INFERIOR 

RADIO-ULNAR). 

In connection with fractures of the lower end of the radius this 
accident is not very uncommon. I have myself met with it under 
these circumstances several times ; but without a fracture it is quite 
rare. Dupuytren met with but two cases in his long and extensive 
practice. Sir Astley Cooper does not record a single instance, and 
many surgeons affirm that they have never seen the dislocation in 
question. 

I 1. Dislocations of the Lower End of the Ulna Backwards. 

To the eleven or twelve examples collected and referred to by Mal- 
gaigne, I am only able to add two cases of ancient luxation seen by 
myself. 

Causes. — Duges mentions the case of a little girl in whom the acci- 
dent occurred in both arms, but at different periods, by being lifted by 
the hands. One of the patients seen by Desanlt, a child five years old, 
had the ulna dislocated backwards by extension accompanied with 
forced pronation, and in another example, cited by him, forced prona- 
tion alone, as in wringing wet clothes, w T as found to have been suffi- 
cient. In Herteaux's case the patient had fallen upon her wrist. 

Pathological Anatomy. — Rupture of the synovial membrane (sacci- 
form ligament), and also of the ligament which binds the ulna to the 



DISLOCATIONS OF LOWER END OF ULNA BACKWARDS. 653 

cuneiform bone : the little head or lower extremity of the ulna aban- 
doning its socket in the radius, and being thrown backwards, or in 
some cases backwards and outwards, so as to cross obliquely the lower 
end of the radius ; or it may incline inwards as well as backwards. 

House Surgeon Owen, of Bellevue Hospital, called my attention, 
April 4, 1869, to an example of this dislocation in ward 28. The 
patient, Mary Fay, set. 27, having puerperal mania, was confined some 
time in February, in a strait-jacket, and the accident happened during 
this confinement, about six weeks before she came under my notice. 
I found the right ulna displaced backwards so that its artiular surfaces 
were completely separated ; but it did not override the radius, and 
with moderate pressure it was returned to place. The dislocation and 
reduction, which had been frequently made by the house staff since the 
accident, caused no pain, but was accompanied with a slight grating 
sensation. 

Dr. Moore, of Rochester, has found this dislocation existing in con- 
nection with a Colles fracture. In the chapter on fractures of the 
radius I have made especial reference to the views of this distinguished 
surgeon upon this subject. 

Several examples are mentioned also in which the end of the bone 
has been thrust completely through the integuments. 

Prognosis. — In recent cases the reduction has generally been accom- 
plished without difficulty, and in only three or four instances nas the 
bone become spontaneously displaced. 

Loder reduced the ulna after eight weeks, and Rognetta after sixty 
days. In one of the examples to which I have already referred as 
having been seen by myself, the dislocation had existed twenty years, 
the accident having occurred in Ireland when the person was fifteen 
years old. When I examined the arm, July 21, 1850, the right ulna 
projected backwards and a little outwards, about half an inch. He 
said he had been- lame with it for several years, but the motions of the 
wrist-joint were now completely restored, and both pronation and su- 
pination were perfect. 

Symptoms. — The hand is usually fixed in a position midway between 
supination and pronation. Boyer, however, found the hand in a state 
of extreme pronation. The extremity of the ulna is felt and seen dis- 
tinctly upon the back of the wrist, prominent and movable ; and the 
styloid process is no longer in a line with the metacarpal bone of the 
little finger; the fingers, hand, and forearm are slightly flexed. 

Treatment. — The reduction may be accomplished by holding firmly 
upon the radius and at the same moment pushing the ulna forcibly 
toward its socket ; or by simply supinating the hand strongly. Some 
cases demand also extension and counter-extension. 

Generally the bone has been found to remain in its place without 
assistance, yet in three or four of the examples upon record the con- 
stant tendency to displacement when the pressure was removed has 
rendered it neceesary to employ splints and compresses. 



654 DISLOCATIONS OF THE LOWER END OF ULNA. 



I 2. Dislocations of the Lower End of the Ulna Forwards. 

The dislocation forwards is said by Malgaigne to be more rare than 
the dislocation backwards. In addition to the nine cases collected by 
him, I have been able to add one reported by Parker, of Liverpool ; 
leaving, therefore, a difference of only three or four in favor of the 
luxation backwards ; and not sufficient, I think, to warrant any posi- 
tive conclusions as to the relative frequency of the two accidents. 

While the dislocation backwards is usually caused by violent pro- 
nation of the hand, this dislocation is most often occasioned by violent 
supination. The hand is therefore generally found to be supinated 
forcibly, and the projection formed by the end of the bone is seen upon 
the front of the wrist instead of the back. 

By pushing the ulna toward its socket while an attempt is made to 
flex the handj or by extension, supination, etc., it is made to resume its 
position readily. In the case reported by Parker, however, the reduc- 
tion w r as effected only while the hand was pronated. 

Parker's case, already referred to, is thus related : 

" John Dalton, aged forty, applied to the hospital Aug. 9th, 1841, 
under the following circumstances : 

" States that he is a carter, and falling down, the shaft of the cart 
fell upon his hand and forearm, in such a way as to supinate them 
forcibly. He complains of pain in the left wrist. The forearm is 
supinated, and cannot be pronated, the attempt causing much suffering. 
The wrist-joint can be flexed or extended without much pain. On 
looking at the back of the wrist, the appearance is characteristic ; the 
natural prominence of the ulna is wanting ; an evident depression 
exists, as if the lower end of the ulna had been dissected out ; it can be 
traced, however, on a plane anterior to the radius, its button-like head 
being distinctly felt under the flexor tendons. Several ineffectual and 
very painful attempts were made to accomplish the reduction, by push- 
ing the head of the ulna into its natural situation. This was at last 
effected by seizing the hand to make extension (counter-extension 
being made at the elbow), then forcibly pronating the hand, at the 
same time pressing backwards the dislocated head of the bone with 
the fingers of the left hand. After persevering for a short time, the 
bone was felt to assume its natural position, the wrist acquired its 
usual appearance, and the ordinary movements of the joint could be 
readily performed. There was no tendency to redislocation, and the 
man was dismissed with directions to keep the bone quiet, and to 
foment it. He attended as an out-patient for two or three days, after 
which, complaining of nothing but a little weakness in the part, a 
bandage was applied, and ordered to be worn for a short time." 1 



1 Parker, Amer. Journ. Med. Sci., April, 1843, p. 470; from Lond. and Edin. 
Month. Journ. Med. Sci., Dec. 1842. 



DISLOCATIONS OF THE CARPAL BONES. 655 



CHAPTER XII. 

DISLOCATIONS OP THE CARPAL BONES (AMONG THEMSELVES). 

Bound together on all sides by strong ligaments, and enjoying only 
a very limited degree of motion among themselves, the carpal bones 
seldom become displaced except in gunshot wounds, or in connec- 
tion with extensive lacerations and fractures of the neighboring parts. 
Simple dislocations, or rather subluxations of these bones, do, however, 
occasionally take place, but, so far as we have been able to ascertain, 
only in one direction, namely, backwards. 

The bones of the carpus, which are* said occasionally to have suffered 
simple backward subluxation, are the semilunar, cuneiform, and pisiform 
of the first row, and the magnum of the second row. 

Richerand, the editor of Boyer's Lectures, says that he once met 
with a subluxation of the os magnum backwards, of which he has given 
us the following account : " Mrs. B., in a labor pain, seized violently 
the edge of her mattress, and squeezed it forcibly, turning her wrist 
forwards ; she instantly heard a slight crack, and felt some pain, to 
which her other sufferings did not allow her to attend. Fifteen days 
afterwards, happily delivered, and recovered by the care of Professor 
Baudelocque, she showed her left hand to this celebrated accoucheur,, 
and expresssed her disquietude about the tumor which appeared on it,, 
especially when much bent. I was called to visit the lady. I found 
that this hard circumscribed tumor, which disappeared almost totally 
by extending the hand, was formed by the head of the os magnum, 
luxated backwards ; I replaced it entirely by extending the hand, and 
making gentle pressure on it. As the affection did not impede the 
motion of the part, as the tumor disappeared on extending the hand, 
and as it would have been but little apparent in any state of the hand 
had Mrs. B. been more in flesh, I advised her not to be uneasy about 
it, and to apply no remedy to it." 1 

Richerand adds also that Boyer and Chopart had each met with the 
same dislocation. 

Bransby Cooper saw the os magnum displaced backwards in a stout, 
muscular young man, by a fall upon the back of the hand when in ex- 
treme flexion. The hand remained slightly bent, and the projection of 
the os magnum was very distinct. Reduction was attempted by extend- 
ing the whole hand, at the same time making pressure upon the dis- 
placed bone ; this not succeeding, extension was made from the middle 
and forefingers only, while pressure was kept up on the os magnum, 
when suddenly the bone resumed its natural position. On flexing the 

1 Richerand, Boyer's Lectures on Diseases of Bones, Amer. ed., 1805, p. 261... 



656 DISLOCATIONS OF THE CARPAL BONES. 

hand, however, the dislocation was immediately reproduced ; and it 
became necessary to apply a compress and splint. For several days 
after, he was in the habit of pushing it out by flexing the hand, in order 
that the young men at Guy's Hospital might see its reduction ; which 
was always easily accomplished by simple pushing upon it. 

Sir Astley says that both the os magnum and cuneiform are some- 
times thrown a little backwards, from simple relaxation of the liga- 
ments, producing a great degree of weakness, so as to render the hand 
useless unless the wrist be supported; and he mentions the case of a 
young lady in whom the os magnum was thus displaced, and who was 
obliged to give up her music in consequence ; for when she wished to 
use her hand, she was compelled to wear two short splints, made fast 
to the back and forepart of the hand and forearm. Another lady, 
whose hand was weak from a similar cause, wore, for the purpose of 
giving it strength, a strong steel chain bracelet, clasped very tightly 
around the wrist. 1 

Gras has described a dislocation of the pisiform bone, 2 and Fergus- 
son says he has known an example in which this bone was detached 
from its lower connections by the action of the flexor carpi ulnaris. 3 
Little benefit, he thinks, can be expected from any attempts to keep it 
in place when it is dislocated, nor is its displacement of much conse- 
quence. Erichsen thinks he has seen a dislocation of the os lunare 
produced by a fall upon the hand when forcibly flexed. By extension 
and pressure it was easily replaced, but when the hand was flexed the 
dislocation was immediately reproduced. 4 

Notwithstanding that Sir Astley, Miller, and others have taught that 
the cuneiform bone is liable to displacement, and that South has affirmed 
the same of the unciform, I have found no account of an example of 
simple dislocation of single carpal bones except in the cases of the os 
magnum, pisiformis, and lunare, as above mentioned. 

Maisonneuve has reported an example of simple dislocation, without 
wound of the integuments, at the middle carpal articulation. A man 
had fallen forty feet, and was carried dying to the Hotel Dieu. The 
symptoms were almost precisely those of a dislocation of both rows of 
the carpal bones backwards. The reduction was not accomplished 
during life, but after death a simple effort of traction was sufficient to 
replace the bones. The dissection showed that the bones of the second 
row were almost completely separated from those of the first, upon 
which they were overlapped backwards. A small fragment of both 
the scaphoids and cuneiform remained attached to the second row, but 
with this exception, the separation was complete. 5 



1 Sir A. Cooper, op. cit. , p. 435. 

2 Note to Chelius, by South, op. cit., p. 234. 

3 Fergusson, op. cit., p. 190. 

4 Erichsen, Science and Art of Surg., Amer. ed., 1859, p. 259. 

5 Maisonneuve, Malgaigne, op. cit., from Mem. de la Soc. de Chirurg., t. 



DISLOCATION OF THE METACARPAL BONES. 657 



CHAPTEE XIII. 

DISLOCATION OF THE METACARPAL BONES (AT THE CARPO- 
METACARPAL ARTICULATIONS). 

The metacarpal bone of the thumb may be dislocated either back- 
wards or forwards. The backward is the most frequent; and it may 
be produced by a fall upon the back of the distal extremity of the 
thumb, which throws it into a state of extreme flexion : it has also 
been occasioned by a force acting in an opposite direction, as when a 
flask of powder is exploded in the palm of the hand, or a blow is re- 
ceived upon the extremity and palmar aspect of the last phalanx. 

The dislocation may be partial or complete. In the few examples 
of partial dislocation which have been recorded, the position of the 
finger has been either moderately flexed or straight, and the signs of 
the accident have been occasionally so obscure as to have led to an 
error in the diagnosis, and the luxation has remained unreduced. 
When the dislocation is recognized, reduction is in most cases easily 
accomplished by pressure, combined with extension ; after which it is 
sometimes necessary to apply a splint to maintain the apposition. If 
the reduction is not accomplished, the joint is permanently maimed. 

Complete backward luxations are more frequent than incomplete, and 
are produced by the same class of causes; generally by a fall upon the 
palmar surface of the thumb. 

The symptoms are sufficiently clear, although the position of the 
thumb is not always the same. It has been found perfectly straight, 
without any inclination either way, or flexed more or less, with the 
metacarpal bone also inclined inwards toward the palm. The motions 
of the joint are interrupted, and the proximal extremity of the meta- 
carpal bone riding upon the back of the trapezium, projects sensibly 
in this direction, and the trapezium is also felt unusually prominent 
under the thenar eminence. The overlapping varies from a line or 
two to three-quarters of an inch. In the patient mentioned by Bour- 
guet, the head of the metacarpal bone almost reached the styloid pro- 
cess of the radius. 

The reduction is to be effected by extension alone, or by extension 
with moderate pressure. 

In two of the examples reported, although the reduction was accom- 
plished very easily, the dislocation w T as reproduced when the extension 
ceased, and it became necessary to apply splints. Malgaigne did not 
observe, in the case seen by him, any such tendency to displacement. 

In the case of Bourguet's patient the reduction was never accom- 
plished, although the attempt was made on the second day by a sur- 
geon, and repeated after about two months by Bourguet himself. 

Fergusson, who has met with several of these dislocations, says that 



658 DISLOCATION OF THE METACAEPAL BONES. 

he has seen even a splint and roller fail of keeping the .bones in place; 
and he recommends, for the purpose of security, that the splint should 
extend some distance upon the forearm. 

Sir Astley Cooper says that, in the cases of this accident which he 
has seen, the metacarpal bone of the thumb has been thrown inwards, 
between the trapezium and the root of the metacarpal bone supporting 
the forefinger; forming a protuberance toward the palm of the hand; 
the thumb has been bent backwards, and adduction was impossible. 

This distinguished surgeon cites no examples, nor are we able to 
find upon record an instance of complete inward dislocation of this 
bone, such as Sir Astley has described. 

Yidal (de Cassis) believes that he has met with a partial forward 
dislocation, which he reduced readily, but the patient having removed 
the retentive means, the dislocation was reproduced and the bone was 
not again replaced. 1 

Malgaigne has collected only three examples of a dislocation of either 
of the other metacarpal bones. One, observed by Bourguet, was a dis- 
location forwards of the metacarpal bone of the index finger, having 
been caused by a great force applied to the back of the phalanx near 
the carpus. Reduction was effected by extension and pressure, the 
bone resuming its place insensibly and not suddenly. With the aid 
of splints it was retained in position, and the cure was perfect. The 
second, seen by Roux, was a backward luxation at the carpo-metacar- 
pal articulation of the second, or great finger, produced by an explo- 
sion in a mine. By pressure made directly upon the projecting bone 
he was .unable to reduce it, but by uniting pressure with extension 
from the finger, he succeeded readily. After the reduction was effected, 
it was noticed that when the hand was straightened the bone became 
reluxated, but that it was easily kept in place when the hand was 
flexed. The third example (occurring in the same joint), mentioned 
by Malgaigne, occasioned by a fall upon the clenched hand, was prob- 
ably incomplete, and Malgaigne is not quite certain that it was not a 
fracture. 

The following very instructive case of forward luxation of the second 
metacarpal bone at its proximal end, has been reported to me by Dr. 
J. Marsh, Asst. Surgeon U. S. A. 

On the 1st of April, 1868, Corporal Charles C, set. 25, was struck 
accidentally on the back of his right hand by a hammer weighing seven 
pounds. The hand was at the time firmly clenched, and covered with 
a buckskin glove. The blow was received obliquely. Dr. Marsh saw 
him half an hour after the accident. A marked depression was readily 
discovered on the back of the hand, corresponding to the proximal 
end of the bone, and from this point a gradual elevation of the bone 
could be traced to its natural level at the distal end. On the palm of 
the hand the displacement was equally manifest. In this position it 
was fixed, and seemed immovable. It was easily and quickly reduced, 
however, by making extension from the fingers, while at the same 
moment pressure was made by the thumb in the palm of the hand. 

1 Vidal (de Cassis), Traite de Pathologie Externe, etc., 3d Paris ed., t. ii, p. 564. 



DISLOCATION OF THE METACARPAL BONES. 659 

It returned to its place with the usual sensation accompanying a reduc- 
tion of a dislocation, and the deformity at once disappeared ; a ball of 
tow was now placed in the palm of the hand, and secured there by a 
roller. On the 13th of April he returned to duty, but his hand did 
not acquire its full strength for some time longer. 

The following example of dislocation of all the metacarpal bones, 
except that of the thumb, is probably without a parallel. Corporal 
Garrigan, at the battle of Fredericksburg, Dec. 13th, 1862, while 
holding his gun at " ready," was hit by a ball on the back and ulnar 
side of his left hand, the ball traversing the back of the hand between 
the last row of carpal bones and the skin, and emerging on the radial 
side, sending the carpal bones forwards and dislocating the metacarpal 
bones backwards. Great swelling ensued, and the nature of the acci- 
dent was not known for some months. When I examined the hand, 
five years later, the displacement was very conspicuous; no fragments 
of bone had ever escaped. The motions of all the fingers, except the 
index and little fingers, were unimpaired. 

In April, 1849, Stephen Peterson, set. 24, was admitted into the 
Buffalo Hospital of the Sisters of Charity, with a partial dislocation 
backwards of the proximal ends of the metacarpal bones of the index 
and great fingers of the right hand; produced, as he affirms, by strik- 
ing a man with his clenched fist, about one year previous. He says 
that he called upon a surgeon immediately, but he was unable to keep 
the bones in place. The projection was very manifest at the time of 
my examination, and the hand had never recovered the power of grasp- 
ing bodies firmly. 

During the same year I found in the hospital a precisely similar 
case, in the person of Francis McCoit, set. 32, a sailor, which had oc- 
curred four years before, in consequence of a blow given with his fist. 
The same bones were partially displaced backwards, and remained 
unreduced. This man had also consulted a surgeon soon after the in- 
jury was received. 

In both of the above examples I instituted a careful examination to 
determine whether it was not the bones of the carpus which were thus 
displaced ; but the result was conclusive as to the nature of the acci- 
dent, and I have obtained casts of both, in order to illustrate partial 
dislocations of the metacarpal bones. 

In 1866 I met with a similar case, only that the metacarpal bone of 
the index finger was alone dislocated, at Bellevue Hospital, in a woman 
28 years of age, caused by falling upon her hand with the fingers 
closed. Reduction was easily effected. 



660 OF FIRST PHALANGES OF THUMB AND FINGERS. 



CHAPTER XIV. 

DISLOCATIONS OF THE FIRST PHALANGES OF THE THUMB 
AND FINGERS (METACARPOPHALANGEAL). 



Fig. 280. 



\ 1. Dislocations of the First Phalanx of the Thumb Backwards. 

This bone may be dislocated backwards or forwards, but most fre- 
quently the dislocation is backwards. I have met with the backward 
dislocation nine times, and the forward twice. 

The backward dislocation is occasioned generally by a fall or blow 
upon the distal end and palmar surface of the thumb ; the proximal 
extremity of the first phalanx sliding back upon the distal extremity 
of the metacarpal bone, and standing off from it at an angle, the last 
being again flexed upon the first phalanx ; mean- 
while the distal end of the metacarpal bone is 
seen projecting strongly in the palm of the hand. 
(Fig. 286.) 

These are the usual signs which characterize 
this accident, and they are always sufficiently 
diagnostic. In a few cases, however, the pha- 
langes have been found extended upon the meta- 
carpal bone in almost a straight line. I have 
twice found them in this position. 

The reduction is sometimes, in recent cases, 
accomplished with great ease, as the following 
examples will illustrate. 

A servant girl, set. 25, fell down a flight of 
steps Nov. 15th, 1850, striking upon the inside 
of her right hand and thumb. When I saw her, 
only a few minutes afterwards, I found the first phalanx standing back 
almost at a right angle with the metacarpal bone, and the second pha- 
lanx also flexed to a right angle with the first. Assisted by my pupil, 
Mr. Board man, the reduction was effected in about twenty seconds, by 
bending the first phalanx farther back, and at the same moment press- 
ing the proximal end of this phalanx forwards in the direction of the 
joint. Without employing great force, the reduction took place sud- 
denly and with a snap. Very little swelling followed, and in three 
weeks she was able to use her needle without inconvenience. 

Michael Wolfe, set. 35, fell from a height, causing a fracture of his 
left arm, and a dislocation of his right thumb backwards. I saw him 
within two hours after the accident. The thumb was much swollen, 
and its position the same as in the case just described. Although 
Wolfe was a strong, muscular man, the reduction was accomplished in 
a few seconds by applying over the last phalanx the Indian toy called 




Dislocation of the first 
phalanx of the thumb 
backwards. 



FIRST PHALANX OF THE THUMB BACKWARDS. 661 

a " puzzle," and making extension in a straight line, while an assistant 
made counter-extension from the hand and wrist. The use of the 
joint was soon completely restored. 

Examples, however, are constantly occurring, which are only re- 
duced after long-continued and painful efforts, or which, indeed, com- 
pletely exhaust the patience and baffle the skill of the most experienced 
surgeons. 

Mary J. S., set. 23, fell upon her right hand with her fingers and 
thumb extended, in September, 1853, and dislocated this bone back- 
wards. A young surgeon attempted to reduce the dislocation half an 
hour after the accident, by the same manoeuvre adopted by myself 
successfully in the case of the servant-girl ; only that he made exten- 
sion upon the last phalanx at the same moment. The surgeon believes 
that the bone was reduced, but one week later he found it displaced, 
and, as he believes, reduced it again. The same thing occurred a third 
time. 

Six months after this, the girl consulted me to ascertain what could 
be done for her relief. The thumb occupied the usual position, and 
admitted of no motion except at the carpo-metacarpal articulation. 

It is quite probable that the dislocation was never reduced, an error 
which, if it did occur, might easily be excused, when we remember 
that from the first the thumb was greatly swollen. 

In May, 1848, having been called to see G. H., who had attempted 
suicide by cutting his throat, my attention was arrested by the appear- 
ance of his left thumb, and which I found to be occasioned by an 
ancient dislocation of the first phalanx backwards. The accident had 
occurred, he afterwards told me, twelve years before, in consequence of 
a fall while wrestling. A very respectable country surgeon was called, 
and made three several attempts to reduce it, but failed. 

The several bones of the thumb occupied their usual positions, that 
is to say, the positions which they usually occupy in this dislocation, 
yet notwithstanding the almost complete anchylosis of the phalangeal 
articulations, and the awkward encroachment of the distal end of the 
metacarpal bone upon the palm, the hand was quite useful. 

In September, 1864, I found in my service at the Charity Hospital 
(BlackwelPs Island), New York, an unreduced dislocation of this kind 
in a girl. The surgeons had tried to reduce it, but had failed. 

On the 25th of July, 1857, Catharine Ernst was brought to me, by 
her parents, having a dislocation of the first phalanx of the right hand, 
which had already existed some days, and upon which several unsuc- 
cessful attempts at reduction had been made. The dislocation was 
backwards, but the phalanges, instead of standing at an acute or right 
angle with each other and with the metacarpal bone, as is usually the 
case, were in a straight line with each other and parallel with the 
metacarpal bone. Whether this phenomenon existed from the first, or 
was due to the efforts already made at reduction, I could not determine, 
but the same thing has been noticed occasionally by other surgeons. 
The first phalanx, moreover, instead of being placed directly behind 
the metacarpal bone, occupied a position upon its back a little to the 
radial side of the centre. 



662 OF FIRST PHALANGES OF THUMB AND FINGERS. 

During quite half an hour I made continued and varied attempts to 
reduce the bone by extension, by forced dorsal flexion, and by pressing 
the upper end of the first phalanx in the direction of the joint while 
pressure was made against its lower end so as to bring it into dorsal 
flexion, and finally by calling to my aid the "puzzle" and chloroform, 
but all to no purpose. 

One week later I repeated these efforts, and with no better success. 
The parents peremptorily refused to allow me to cut the lateral liga- 
ments or flexor tendons, so the bone remains unreduced. 

In the following case the relative position of the bones was the same 
as in the preceding case, but the reduction was not difficult. 

Bernard Lawler, set. 10, was admitted to Bellevue Hospital in Jan- 
uary, 1864, with a fracture of the femur and other severe injuries. 
The dislocation of the thumb was not noticed until the ninth day. 
The reduction was then easily accomplished, in presence of the class 
of medical students, by forced backward flexion. 

Surgical writers have recorded, from time to time, a great many 
cases in which it has been found difficult or impossible to effect re- 
duction; and it is asserted upon the authority of Bromfield, quoted by 
Hey, that the extending force has been increased to such an amount as 
to tear off the last phalanx without having succeeded in reducing the 
first ; but while surgeons have united in their testimony as to the ex- 
ceeding obstinacy of a large proportion of these dislocations, they are 
far from being agreed as to the source of the difficulty. 

Sir Astley Cooper finds a sufficient explanation in the six short and 
powerful muscles which are inserted into the first and last phalanx, 
and especially in the flexors. 1 Hey believes the resistance to be in the 
lateral ligaments between which the lower end of the metacarpal bone 
escapes and becomes imprisoned. Ballingall, Malgaigne, Erichsen, 

and Vidal (de Cassis) think the meta- 
fig. 287. carpal bone is locked between the two 

heads of the flexor brevis, or rather be- 
tween the opposing sets of muscles which 
centre in the sesamoid bones, as a button 
is fastened into a button-hole. Pailloux, 
Lawrie, Michel, Leva, Blechy, and Roser 
affirm that the anterior ligament being 
torn from one of its attachments, falls 
between the joint surfaces and interposes 
an effectual obstacle to reduction. Du- 
puytren ascribes the difficulty to the al- 
tered relations of the lateral ligaments, 
ciove hitch. which are naturally parallel to the axis 

of the metacarpal bone, but which are 
now placed at a right angle ; to the spasm of the muscles, and to the 
shortness of the member, in consequence of which the force of extension 




1 Lawrie, of Glasgow, says that Sir Astley in a conversation with him declared 
that the " sesamoid bones " were the sources of the difficulty. See Amer. Journ. 
Med. Sci., vol. xxii, p. 230, with observations and experiments by Lawrie. 



FIRST PHALANX OF THE THUMB BACKWARDS. 663 

has to be applied very near to the seat of the dislocation. Lisfranc 
found in an ancient luxation the tendon of the long flexor so displaced 
inwards and entangled behind the extremity of the bone as to prevent 
reduction. Deville discovered in an autopsy a similar displacement 
of this tendon outwards. Wadsworth has made the same observation. 1 

The modes of reduction practiced and recommended by these differ- 
ent surgeons are as diversified and irreconcilable as their views of the 
mechanism and pathological anatomy of the accident. 

Sir Astley Cooper recommends that extension shall be made by 
bending the thumb toward the palm of the hand, to relax the flexor 
muscles as much as possible, and then, by fastening a clove hitch upon 
the first phalanx, previously covered with a piece of soft leather, the 
extension is to be continued, only inclining the thumb a little inwards 
tow r ard the palm of the hand. If these means fail after having been 
continued a considerable length of time, he advises that a weight shall 
be suspended to the thumb, passing over a pulley. Finally, in the 
event of the failure of this method also, Sir Astley thought that no fur- 
ther attempts should be made, and especially that no operation for the 
division of these parts is justifiable. 

Lizars and Pirrie adopt the views of Sir Astley with little or no 
qualification. 

Fig. 288. 




Sir Astley Cooper's method of reducing dislocations of the thumb, with pulleys. 

Charles Bell proposed flexing the joint, employing also at the same 
time pressure ; and in obstinate cases he advised subcutaneous section 
of the lateral ligaments with a small knife, a method which has since 
been practiced successfully by Liston, Peinhardt, Gibson, of Philadel- 
phia, Parker, of New York, and others. Syme and Lizars justify the 
practice in certain cases. In one case which has come under my notice, 
after failing to effect reduction by the usual methods, I succeeded 
promptly after cutting one lateral ligament ; and in the second case I 
only succeeded after cutting both lateral ligaments. 

Poser, from his experiments upon the cadaver, concludes that the 
dislocated phalanx must first be bent forcibly backwards, or into the 
position termed by some waiters dorsal flexion, so as to throw the head 
of the phalanx forwards upon the articulating surface of the metacarpal 
bone. Parker, of New York, in his notes to the American edition of 
Samuel Cooper's work, recommends the same procedure. 

Vidal (de Cassis) recommends also that the extension should be made 
first backwards, so as to increase the displacement of the first phalanx 

1 Wadsworth, Amer. Med. Times, Feb. 13, 1864, p. 77. 



664 OF FIRST PHALANGES OF THUMB AND FINGERS. 

in this direction, and to throw forwards its articular surface in the di- 
rection of the articular surface of the metacarpal bone. 

This method, namely, dorsal flexion, as the first and most essential 
part ot the manoeuvre, seems to have met with more general approval 
than any other, and the following observations, made by the late Keuben 
V. Mussey, of Cincinnati, illustrate the general practice among Ameri- 
can surgeons at this day. b 

" I tilt the dislocated phalanx up until it stands upon its articulating 
end, place both forefingers so as to hold it in that position, and at the 
same tame press against the distal extremity of the metacarpal bone 
make firm pressure with the thumbs against the base of the dislocated 
phalanx, and slide it into its place, which can generally be accomplished 

" More than twenty-five years ago, the chairman of this committee, 
from attention to the mechanism of the metacarpophalangeal joint of 
the thumb, convinced himself that the principal impediment to the re- 
duction of the first phalanx from backward displacement is the short 
flexor of the thumb, between the two portions of which (lying close 
together where they are fastened to the sesamoid bones) the heacl of the 
metacarpal bone has been thrust, the contracted part or neck of this 
bone lying firmly grasped by them. Fifteen years ago, a case oc- 
curred of this dislocation which he could not reduce in the ordinary 
way. A subcutaneous division of one of the heads of this muscle was 
made with an iris knife, and the reduction was accomplished with the 
greatest ease. 

" Last year another case occurred, in which we failed of reduction by 
Dr. Crosby's method, which we believe to be the best, and the subcu- 
taneous division of both heads of the muscle was made, and the reduc- 
tion instantly effected. The punctures were covered with collodion 
and the thumb supported by a splint. As the patient was intemperate' 
entire abstinence from liquor and the adoption of a light diet were en- 
joined. N eIther pain nor i n fl ammation followed, and a month after- 
wards the joint had free motion. After the intemperate and irregular 
habits were resumed, the joint in a few weeks was found anchylosed. 
In these cases, the knife, in the subcutaneous operation, was carried 
down to the metacarpal bone, so far behind its head as to preclude the 
possibility of mistaking the lateral ligaments for the muscles. The 
ligaments are very short, and inserted close to the articular surfaces, 
and are probably, one or both, ruptured in this dislocation." 1 
v ,i 5" BatcheIder > of New York, in a paper read before the New 
York Medical Association in 1856, says: "The surgeon should take 
the metacarpal portion of the dislocated thumb between the thumb and 
finger of one hand, and flex or force it as far as may be into the palm 
of the hand, for the purpose of relaxing the muscles connected with 
the proximal end of the phalanx, particularly the flexor brevis pollicis. 
He should then apply the end of the thumb of his hand against the 
displaced extremity of the dislocated phalanx, for the purpose of forc- 
mg it downwards, and at the same time grasp the displaced thumb with 

1 Mussey, Trans. Amer. Med. Assoc., vol. iii, 1850, p. 357. 



FIKST PHALANX OF THE THUMB BACKWARDS. 665 

his other hand, and move it forcibly backwards and forwards, as in 
strongly forced flexion and extension, the pressure against the upper 
extremity of the first phalanx being kept up. In this way the dislo- 
cated bone may be made to descend, so as to be almost or quite on a 
line with the articulating surface of the metacarpal bone, when the 
thumb may be forcibly flexed, and, if it be not reduced, as forcibly ex- 
tended, and brought backwards to a right angle with the metacarpal 
bone; when, if the downward pressure, with the thumb placed as before, 
directed for that purpose, has been continued (which thumb, by main- 
taining its position, acts as a fulcrum, as well as by its pressure), the 
bone will slip into its place, and the reduction be effected in less time 
than has been spent in describing the process. 7 ' 1 

Six successive cases of treatment by this method are mentioned in 
the American Journal of Medical Sciences for April, 1858 ; one by 
Rickard, one by Morgan, two by Cutter, and two by Crosby. I have 
also once succeeded by the same method. 

By those who have regarded extension as an important element in 
the reduction, various instruments have been devised for the purpose 
of obtaining a secure hold upon the dislocated member. Sir Astley 
Cooper, as we have already seen, recommended the sailor's clove 
hitch f Lawrie advises that the thumb shall be thrust into the open 
handle of a large door key f Charriere and Luer, of Paris, have each 
invented forceps, so constructed with fenestra and straps, as that when 
the blades are closed the member is held very firmly in its grasp. 
Richard J. Levis, of Philadelphia, recommends " a thin strip of hard 
wood, about ten inches in length, and one inch, or rather more, in 



Fig. 289. 




Levis's instrument for reduction of dislocations of fingers or the thumb. 

width. One end of the piece is perforated with six or eight holes. 
The opposite end is partly cut away, forming a projecting pin, and 
leaving a shoulder on each side of it. Towards this end of the strip, 
a sort of handle shape is given to it, so as to insure a secure grasp to 
the operator. Two pieces of strong tape or other material, about one 
yard in length, are prepared. One of these is passed through the 
holes at the end of the strip, leaving a loop on one side. The other 
tape is passed through another pair of holes, according as it may be a 
thumb or a finger to which it is to be applied, or varied to suit the 



1 Batchelder, New York Journ. Med., May, 1856, p. 340. 

2 Op. cit, p. 561 ; also Bost. Med. and Surg. Journ., Oct. 1, 1857. 



3 Lawrie, Am. Journ. Med. Sci., vol. xxii, p. 229. 

43 



6Q6 OF FIRST PHALANGES OF THUMB AND FINGERS. 

length of the finger, leaving a similar loop. If a dislocated thumb is 
to be acted on, the second tape should be passed through the holes 
nearest the first. The ends of each separate tape are then tied together. 
" To apply this apparatus, the finger is passed through the loops. 
The loop nearest the first joint is then tightened by drawing on the 

Fig. 290. 




Levis's instrument applied to the first finger. 

tape, which is then brought along the strip to the opposite end, across 
one of the shoulders, and secured by winding it firmly around the 
projecting pin. The other tape is tightened in a like manner, crossing 
the other shoulder, and winding around the pin in an opposite direc- 
tion, when, for security, the ends of the tapes are finally tied together." 1 

This apparatus enables the operator to apply both extension and 
flexion or leverage in any direction. The proximal end of the pha- 
lanx may be lifted, or even rotated so as to allow one side of the bone 
to approach the socket before the other. 

Malgaigne describes an apparatus invented by Kirchoff/ which is 
very similar to, yet not quite so complete as this of Levis. 

In the April number of the Buffalo Medical Journal, for 1847, I 
have described an instrument, or rather a toy, in my possession, which 
I suggested might be useful for the purpose of making extension upon 
dislocated fingers j and which, as will be seen by a reference to one of 
the cases already reported in this chapter, I have since applied success- 
fully. It is made by the Indians, and may always be obtained during 
the watering season, at the Indian toy-shops at Niagara Falls. The 
Indians call it a " puzzle," and know no other use for it than to fasten 

Fig. 291. 




Indian " puzzle," employed for the reduction of dislocations in small joints. 



it upon the thumb or finger of some victim, and then pull him about 
until he begs to be released. 

The " puzzle " is an elongated cone of about sixteen or eighteen 
inches in length, made of ash splittings, and braided ; the open end of 
the cone being: about three-fourths of an inch in diameter, and the 



1 Levis, Amer. Journ. Med. Sci., Jan. 1857, p. 62. 



FIRST PHALANX OF THE THUMB FORWARDS. 667 

opposite end terminating in a braided cord. When applied to the 
finger, it is slipped on lightly, forming a cap to the extremity, and to 
half the length of the finger, but on traction being made from the 
opposite end, it fastens itself to the limb with a most uncompromising 
grasp. If constructed of appropriate size and of suitable materials it 
becomes the more securely fastened in proportion as the extension is 
increased ; yet, applying itself equally to all the surfaces, it inflicts 
the least possible pain and injury upon the limb. When we wish to 
remove it, we have only to cease pulling, and it drops off spontane- 
ously. 

Dr. Holmes says that the same instrument is made by the Indians 
of Maine, and that several years ago Dr. Davis, of Portland, brought 
one to Boston, and showed it to the Society for Medical Improvement, 
suggesting that it might be used in the same manner which I have 
recommended. 1 

Finally, in some compound dislocations it would be better not to 
attempt the reduction of the dislocation until resection has been prac- 
ticed. Samuel Cooper relates a case in which the reduction was fol- 
lowed by inflammation and death within a week after the accident, 
and Norris, of Philadelphia, mentions an instance which came under 
his observation, where violent inflammation and tetanus followed the 
reduction. 2 Roux, Evans, Wardrop, Gooch, Sir Astley Cooper, and 
many other surgeons, have practiced resection successfully in these 
accidents, and have added their testimony in favor of this mode of 
procedure. 

g 2. Dislocations of the First Phalanx of the Thumb Forwards. 

Up to the present moment, I have met with but two examples of 
this dislocation, while, as has been already stated, the backward dis- 
location has been seen by me nine times. 

Horace Kneeland, of Rochester, N. Y., set. 21, dislocated the first 
phalanx of the right thumb forwards, by striking a man with his 
clenched fist ; the force of the blow being received upon the back of 
the second joint of the thumb. The dislocation had existed three 
days when he called upon me, and in the meanwhile several attempts 
had been made to reduce the bone by simple extension. The first 
phalanx was in front of the metacarpal bone, and in the same plane ; 
but the last phalanx was slightly inclined backwards. The hand was 
already swollen and quite painful. 

Seizing the dislocated thumb in the palm of my right hand, with 
my fingers resting upon the back of the patient's hand, I forced the 
two phalanges into flexion by firm and steady pressure continued for 
a few seconds, when suddenly the bones resumed their places, and all 
deformity disappeared. 

Intense inflammation resulted, followed, after a few days, by suppu- 

1 Trans. Am. Med. Assoc, vol. i, p. 267. 

2 Norris, Amer. Journ. Med. Sci., vol. xxxi, p. 16. 



668 OF FIRST PHALANGES OF THUMB AND FINGERS. 

ration under the palmar fascia; and in the end the thumb was almost 
completely anchylosed. 1 

On the 24th of April, 1855, J. M. Booth, of Buffalo, set. 19, called 
at my office, having a dislocation forwards of the first phalanx, occa- 
sioned, about half an hour before, by being thrown from a horse. The 
last two phalanges were neither flexed nor extended, but straight, and 
parallel with the metacarpal bone. 

By the same manoeuvre adopted in the preceding case, but with 
only very moderate force, the dislocation was promptly reduced. 

The usual causes of this accident are falls or blows upon the thumb 
while it is flexed; and the symptoms which characterize it are, in 
general, such as we have seen in the two examples which have just 
been given. The metacarpal bone projects posteriorly, and the first 
phalanx produces a corresponding projection toward the palm; the 
two phalanges are extended upon each other, and parallel with the 
metacarpal bones. Nelaton saw a case in which the first phalanx was 
flexed about 45° ; and in several examples it has been observed to be 
slightly rotated inwards. 

In the few examples of this accident which have been reported, the 
reduction was easily accomplished; or, at least w T e may say that the 
difficulties in the way of reduction were not so great as they are usually 
found to be in dislocations backwards. Malgaigne has been able to 
collect but four undoubted examples, all of w r hich were reduced; 
Lenoir was able to effect the reduction by moderate measures, after the 
bone had been dislocated thirty-eight days. Ward succeeded by simple 
extension. 2 

Lombard, after the trial of other plans, finally succeeded by revers- 
ing the phalanx. Employing, as we have before termed it, " dorsal 
flexion/' with extension and lateral motion ; but in all, or nearly all 
the other examples, the reduction has been effected by flexing the 
thumb forcibly toward the palm ; the reverse of the method which 
we have seen preferred, especially by American surgeons, in disloca- 
tions backwards. My own experience also authorizes me to recom- 
mend this plan. 

I 3. Dislocations of the First Phalanx of the Fingers. 

The index and little fingers, owing to their exposed situations, are 
most liable to these dislocations. I have met with three examples of 
traumatic dislocations of these joints, one of which was a forward and 
two were backward luxations, and all had occurred in the index finger. 

James Nesbitt, of Buffalo, a?t. 11, dislocated the index finger of the 
right hand, backwards, by a fall down a flight of stairs. On the same 
day, Feb. 11, 1851, he called upon me, and I found the finger neither 
flexed nor extended, but straight and immovable. The projections 
occasioned by the ends of the two bones were very marked, and such 
as to render an error in the diagnosis impossible. Reduction was 
accomplished with great ease, by reversing the finger and employing 

1 Trans. N. Y. State Med. Soc., 1855, p. 73. 

2 Ward, New York Med. Times, Sept. 8, 1860. 



PHALANGES OF THE THUMB AND FINGERS. 669 

moderate extension, while at the same time the proximal extremity of 
the first phalanx was pushed toward the distal end of the metacarpal 
bone. In short, the process was the same as that which we have 
recommended in dislocations of the thumb backwards. 

Fig. 292. 




Backward dislocation of first phalanx. Reduction by extension. 

In the second case, presented in a woman 35 years of age, at Charity 
Hospital, April 16, 1868, the dislocation was caused by her husband 
having pulled the finger violently backwards. The metacarpal bone 
was thrust through the skin on the palm of the hand. Four weeks 
had now elapsed, and the wound had healed. A few days before, the 
house surgeon had placed her under the influence of ether and had 
attempted reduction, but had failed, and she refused to allow me to 
repeat the attempt. 

In the example of dislocation forwards, occasioned by a blow from 
a hard ball, received upon the end of the finger, the first phalanx was 
in a position of extreme extension, and the second moderately flexed. 
Reduction was effected with great ease by extension in a straight line. 
But if the surgeon were to experience difficulty in the reduction, it 
would no doubt be advisable to resort to the method of extreme flexion. 

In one instance, I have seen nearly all the fingers of the left hand, 
and the thumb of the right, dislocated backwards by the contraction 
of the cicatrix after a severe burn. 



CHAPTEE XV. 

DISLOCATIONS OF THE SECOND AND THIKD PHALANGES OF 
THE THUMB AND FINGEKS (PHALANGEAL). 

Notwithstanding slight differences in the form of the articulations 
between the thumb and fingers, and in the size and situation of the 
bones which compose the phalanges of the fingers, we are disposed, 
contrary to the practice of some other writers upon this subject, to con- 
sider all the dislocations to which these several joints are liable, under 
one section. ISTor, indeed, after the attention which we have given to 
the dislocations at the metacarpophalangeal articulations, do we find 
much to add in relation to these accidents ; since in almost every point 



670 



PHALANGES OF THE THUMB AND FINGERS. 



of view in which they may be considered, they have so much in 



common. 



The last phalanx of the thumb is, of all the phalanges, most liable 
to dislocation, and this generally takes place backwards. Very fre- 
quently, also, it is accompanied with such a laceration as to render it 
compound. The dislocated phalanx is usually reversed in the back- 
ward dislocation, and straight, or nearly so, in the forward dislocation. 

In most cases reduction may be accomplished easily by forced dorsal 
flexion in the case of the backward luxation, and by forced palmar 
flexion in the case of the forward dislocation. 

In the winter of 1848, a young man was brought into my clinic, 
who had met with a forward subluxation of this phalanx about one 
month before. He had fallen upon the end of his thumb, and as the 
accident was followed by a good deal of inflammation and swelling, 
he did not notice the displacement until some time afterwards. The 
proximal end of the last phalanx projected two or three lines toward 
the palm; the finger was straight, and this joint anchylosed. I did 
not think the chance of restoring and maintaining the bone in position 
sufficient to warrant any interference, and he was dismissed with an 
assurance that after a few months it would occasion him no great in- 
convenience. 

On the 2d of March, 1851, Thomas Burton, aged about twenty-two 
years, by a fall dislocated the second phalanx of the middle finger of 
the right hand, backwards. The force of the concussion was received 
upon the extremity of the finger. Nine hours after the accident I 
found the bones unreduced; the finger nearly straight, or with only 
slight flexion of the second phalanx upon the first ; the third phalanx 
forcibly straightened upon the second ; all the joints rigid ; finger very 
painful and somewhat swollen. 

By moderate extension alone, applied for a few seconds, the reduc- 
tion was accomplished. 



Fig. 293. 




Dislocation of the second phalanx backwards. 



James Cooper, set. 23, came to me on Sunday morning, the 14th of 
Dec. 1851, to obtain counsel in relation to his finger which had been 
dislocated the day before, but which he had himself reduced by simple 
extension made in a straight line. His own account of it was, that he 
fell upon a slippery sidewalk, striking upon the end of his ring finger 
in such a way that it seemed to double under him. On examination, 
he found the second bone dislocated inwards, or to the ulnar side, com- 
pletely, the end of the first phalanx forming a broad projection upon 
the opposite side; the last two phalanges fell over toward the middle 



PHALANGES OF THE THUMB AND FINGERS. 671 

finger, but they were neither flexed nor extended. Seizing upon the 
end of the finger with his right hand and pulling forcibly, he promptly 
reduced the dislocation himself. 

The bones were now completely in place, but the joints were swollen, 
tender, and quite stiff. 

In Sept. 1851, by the politeness of Dr. Briggs, the attending surgeon, 
I was permitted to see, in the hospital of the New York State Prison, 
at Auburn, a forward dislocation of the second phalanx of the little 



Fig. 294. 




Dislocation of the second phalanx forwards. 

finger of the left hand, unreduced. This man was at the date of my 
examination forty-one years old, and the dislocation had existed eigh- 
teen years ; having been occasioned by a fall. A surgeon in Greene 
Co., N. Y., had attempted to reduce it soon after the dislocation oc- 
curred, but had failed. The joint was nearly anchylosed, yet the finger 
was quite as useful for all ordinary purposes as before. 

Dislocation of the last phalanx is frequently occasioned in the game 
of base ball, by the ball being received upon the extremity of the finger. 

A young man who was studying medicine, and a private pupil ol 
mine, in attempting to catch a very hard ball, received it upon the ex- 
tremity of the middle finger of the left hand, dislocating the last pha- 
lanx forwards. Twenty minutes after the accident, I found the distal 
extremity of the second phalanx projecting backwards through the skin, 
the tendon of the extensor muscle being torn completely off from its 
point of attachment to the last phalanx. The last phalanx was in a 
position of slight dorsal flexion, or extreme extension. 

Seizing upon the extremity of the finger, I attempted to reduce the 
dislocation by direct traction, aided by pressure upon the exposed end 
of the second phalanx, but I was unable to succeed until I brought the 
last phalanx into a position of palmar flexion. 

A slight disposition to reluxation was manifested, and a gutta-percha 
splint was therefore applied; and, to prevent inflammation, the young 
man was directed to keep it moistened with cool water lotions. Only 
a moderate amount of inflammation followed, and in a few weeks the 
cure was complete. 

Such accidents, attended with laceration of the integuments, frequently 
demand amputation, or at least resection of the projecting bone, but we 
think Mr. Miller is scarcely right when he says that compound dislo- 
cations of the fingers almost always are of such severity as to demand 
amputation. I have myself met with three other cases which were re- 
duced, and did well. 



672 



DISLOCATIONS OF THE THIGH. 



In one case of simple dislocation of the last phalanx of the thnml 
backwards I have been obliged to resort to section of the lateral liga- 
ments before accomplishing the reduction. This was in the person oi 
a woman admitted to Bellevue Hospital in February, 1864. The ac- 
cident had happened seven days before, by falling and striking upon 
the end of the thumb. The position of the last phalanx was extended, 
that is, in a line with the axis of the first phalanx. She said, however, 
that it was at first " bent straight back," but that a man took hold of 
it and pulled it out. Having placed her under the influence of ether, 
I attempted reduction by forced backward flexion, but failed. I then 
cut the lateral ligaments by subcutaneous incision, and the reduction 
was accomplished with great ease. 



CHAPTER XVI. 



DISLOCATIONS OF THE THIGH (COXO-FEMORAL). 

The femur is especially liable to dislocation in four directions, 
namely, upwards and backwards upon the dorsum ilii, upwards and 
backwards into the ischiatic notch, downwards and forwards into the 
foramen thyroideum, and upwards and forwards upon the pubes. 

Dislocations are occasionally met with which cannot be arranged 
properly under either of these divisions ; indeed, it is scarcely necessary 
to say that the head of the bone may be thrown in almost every direc- 
tion from its socket, upwards, downwards, inwards, and outwards, or 
in either of the diagonals between these lines; and that while in a vast 
majority of cases it will assume one of the positions -first named, it may 
in a few exceptional examples fall short of, or much exceed, the limits 
assigned in this division. Thus, we shall have occasion hereafter to 
mention examples of dislocation directly upwards, in which the head 
of the bone will be found resting upon the fossa between the upper 
margin of the acetabulum and the anterior inferior spinous process of 
the ilium, or still higher, between the anterior superior and the anterior 
inferior spinous processes, or a little to the one side or to the other of 
these points. Examples will be shown of dislocations directly down- 
wards, in which the head of the femur will rest upon the notch between 
the lower margin of the acetabulum and the tuber ischii, or still lower, 
and actually below the tuberosity, or downwards and backwards below 
the spine of the ischium, into the lower or lesser sacro-sciatic notch. 
The head may be thrust across the foramen thyroideum, and be only 
arrested in the perineum upon the ramus, or even beyond the ramus of 
the ischium and pubes ; it may lodge upon the anterior surface of the 
body of the pubes, as well as upon its superior edge; and finally, it 
may rest against the posterior margin of the acetabulum instead of 
rising upon the dorsum, or it may only mount upon its margin, in 
either of the directions named. 



DISLOCATIONS OF THE THIGH. 673 

In regard to frequency, the four principal dislocations occur in the 
order in which we have mentioned them ; thus, of 104 dislocations of 
the hip which I have taken the pains to collate, excluding the anoma- 
lous or extraordinary dislocations, and which my intelligent pupil, Mr. 
Frank Hodge, has carefully analyzed, 55 were upon the dorsum ilii, 
28 into the great ischiatic notch, 13 upon the foramen thyroideum, and 

upon the pubes. Chelius and Samuel Cooper have, however, re- 
versed the order of the last two varieties, arranging dislocations upon 
the pubes, in the order of frequency, before dislocations into the fora- 
men thyroideum. 

Coxo-femoral dislocations may occur at any period of life ; a case of 
thyroid dislocation is reported in the Lancet for May 16, 1868, which 
occurred in a child six months old. One example is mentioned in the 
Gazette Medicate, of a recent dislocation upon the dorsum ilii, in a child 
eighteen months old. 1 Dr. N. Fanning, of Catskill, N. Y., informs 
me, in a letter dated June 25th, 1867, that he has reduced a dislocation 
upon the dorsum ilii, on the tenth day, in a little girl eighteen months 
old. Mr. Kirby has reported, in the Dublin Medical Press for October 
26, 1842, a case of recent dislocation in the same direction, in a child 
of three years, 2 and Dr. Buchanan has seen another, at the same age, 
in a little girl ; the dislocation being into the ischiatic notch. 3 Mr. 
Image communicated to the Suffolk branch of the Provincial Medical 
and Surgical Association the case of a boy, three and a half years old, 
with a dislocation upon the dorsum ilii. It had existed twelve days 
when he was admitted to the Suffolk Hospital in May, 1847. Mr. 
Image, in reporting this case to the Society, remarked that he had been 
induced to lay it before them "in consequence of a charge having been 
urged against a neighboring surgeon, of pretending to reduce a dislo- 
cation of the femur on the dorsum ilii, in a child only four years old, 
that child being a pauper, and chargeable to the parish. It was agreed 
and proved by authorities that no such case was recorded, and therefore 
had not occurred, and that seven years old was the earliest period at 
which this accident had taken place." 4 

J. M. Litten, of Austin, Texas, reports a case of dislocation upon 
the dorsum ilii in a girl four years old, which he reduced by manipu- 
lation. 5 In the January number for 1847 of the American Journal of 
Medical Sciences is reported a forward dislocation in a boy aged five 
years, and a dislocation into the ischiatic notch in a girl of the same 
age. 

Dr. J. C. Warren, of Boston, met with an incomplete dislocation 
toward the foramen thyroideum in a child six years old, which, having 
been displaced eight or ten weeks, he was unable to reduce. 6 Sir 
Astley Cooper mentions a case in a girl seven years old. 7 I have my- 
self met with two dislocations upon the dorsum ilii, which occurred at 

1 New York Journ. Med., Nov. 1850, p. 416. 

2 Amer. Journ. Med. Sei., vol. xxxi, p. 207, Jan. 1843. 

3 London Med.-Chir. Kev., Dec. 1828, p. 251. 

4 New York Journ. Med., Sept. 1848, p. 281. 5 Ibid., March, 1852, p. 259. 

6 Boston Med. and Surg Journ., vol. xxiv, p. 220. 

7 A. Cooper, on Disloc, Amer. ed., p. 83, Case 27. 



674 



DISLOCATIONS OF THE THIGH. 



ten years, and one into the foramen thyroideum. 1 Norris reports a 
case at eleven years, 2 and Gibson at twelve. 3 On the other hand, Dr. 
P. J. Kline, of Portsmouth, Ohio, has reported to me a case of dislo- 
cation of the femur in a woman aged seventy-three, and which thirteen 
years later he found unreduced ; and Gauthier has seen a dislocation 
of the hip in a woman eighty-six years of age. 4 The large majority, 
however, occur between the fifteenth and forty-fifth years of life. From 
an analysis of eighty-four cases, we have obtained the following results : 

Under 15 years, ........ 15 cases. 

15 to 30 " 32 " 

30 to 45 " 29 " 

45 to 60 " 7 «' 

66 to 85 " 1 case. 

Dislocations of the hip are much more frequent in men than in 
women ; owing, probably, to the greater exposure of the former to the 
accidents from which these dislocations usually result, and possibly, 
also, in some measure, to certain peculiarities in the form and structure 
of the neck of the femur in the male. Of one hundred and fifteen 
cases collected by me, one hundred and four were in males and eleven 
in females. Dr. J. K. Rodgers, of New York, mentioned, however, 
at a meeting of the New York Kappa Lambda Society, that he had 
seen and reduced four dislocations of the femur upon the dorsum ilii 
in females, and that a fifth case had recently come to his knowledge in 
the New York City Hospital. 5 

Gibson mentions an example of dislocation of both thighs at the 
same moment. 6 



I 1. Dislocations Upwards and Backwards on the Dorsum Ilii. 

Syn. — " Upwards on the dorsum ilii ;" Sir A. Cooper, Miller, Pirrie. "Upwards 
and outward ;" Boyer, Dupuvtren. "Upwards and backwards upon the back of 
the hip-bone ;" Chelius. "Iliac;" Gerdy, Vidal (de Cassis), Malgaigne. 

Causes. — Generally they are occasioned by some violence which 
forces the thigh into a state of extreme adduction, or of adduction 
united with rotation inwards ; and especially when at the same mo- 
ment the head of the femur is driven upwards and backwards. Thus, 
a dislocation upon the dorsum may result from a fall from a height, 
w r hen the force of the concussion is received upon the outside of the 
knee: the thigh being thus converted into a lever of the first kind, 
whose long arm is outside of the margin of the acetabulum ; or the 
dislocation may be occasioned by a fall upon the foot or knee, while 
the limb is adducted, by which the head of the femur will be at the 
same moment driven upwards and outwards from its socket. The 
accident is equally liable to result from the fall of a heavy weight, 
such as a mass of earth, upon the back of the pelvis when the body is 
much bent forwards. 



1 Buffalo Med. Journ., vol. viii, p. 6. Trar 
My Report on Disloc 

2 Amer. Journ. Med. Sci , Feb. 1839, p. 296 
4 Gnuthier, Malgaisrne, op eit.. p. 805. 
s J. K. Rodffers, New York Journ. Med , July, 1839, vol. i, first ser , p. 220 
6 Gibson's Surg., vol. i, p. 385, sixth td. 



New York State Med. Soc, 1855. 
3 Gibson's Surg., vol. i, p. 389. 



UPWAEDS AND BACKWARDS ON THE DORSUM ILII. 675 



Fig. 295. 



The following case presents an extraordinary example of this form 
of dislocation produced by a force acting upon the thigh as a lever of 
the first kind : 

B., of Rochester, N. Y., set. 10, fell, in Feb. 1841, from the top of 
the high bank just below the Genesee Falls, at Rochester, a distance of 
about one hundred feet. Before he reached the bottom of the preci- 
pice, he struck upon an oblique plane of ice, from which he slid gradu- 
ally down upon the surface of the river, which was then completely 
frozen over. He did not lose his consciousness in the descent, nor 
after his arrest upon the river, but began immediately to call for assist- 
ance. He remembers very well that when he struck the glacier, the 
concussion was received upon the right side of the right knee, and a 
mark of contusion at this point confirmed his statement. Dr. Ellwood, 
of Rochester, assisted by myself, reduced the dislocation within one 
hour after its occurrence. We employed pulleys, but the reduction 
was accomplished easily in about two minutes, and without the appli- 
cation of much force; the bone resuming its place with an audible 
snap. His recovery was rapid and complete. 1 

Pathological Anatomy. — The capsule is lacerated more or less ex- 
tensively, but especially in its posterior half; the round ligament is 
ruptured ; some of the small external rotator muscles are generally 
stretched or torn completely asunder, the glutseus maximus, medius, 
and minimus are pushed upwards and 
folded upon each other, the head of the 
femur resting upon or within the fibres 
of the deeper muscles; the triceps ad- 
ductor is put upon the stretch. 

Surgeons have not been agreed as to 
the cause of the great difficulty which 
has usually been experienced in the re- 
duction of this and of all other forms of 
coxo-femoral dislocations. While some 
have ascribed it alone to the resistance of 
the muscles, others have with equal con- 
fidence ascribed the opposition to an en- 
tanglement of the head and neck of the 
bone in the rent capsule, or in the liga- 
ment; and still others believe that the 
impediment ought to be looked for some- 
times in the muscles and sometimes in the 
capsule, or in both at the same moment. 

Sir Astley Cooper thought that the 
capsular ligament was generally too much 
torn to offer any impediment to reduction, 
and he refers to some dissections in con- 
firmation of this opinion. Nathan Smith affirmed that the chief ob- 
stacle to reduction by extension was to be found in the resistance 
offered by the gluteii muscles, which, although at first relaxed, would 




Dislocation upon the dorsum ilii. 



1 Trans. New York State Med. Soc, 1855, p. 76. My report on Dislocations. 



676 DISLOCATIONS OF THE THIGH. 

soon become tense under the stimulus of the extension, and which, in 
order that the bone might resume its position, must actually be stretched 
considerably beyond their normal length. 1 W. W. Reid declares that 
the sole resistance is at first in the abductors and rotators, but that 
finally the psoas magnus, iliacus internus, and triceps adductor become 
tense where the pulleys are employed. 2 Chassaignac recognizes no 
other impediment to reduction than the contractions of the muscles. 3 

Dr. Fenner, of New Orleans, gives the particulars of a dissection of 
the hip of a man admitted into the Charity Hospital, who died from 
injuries received by the bursting of a steamboat boiler. His condition 
being considered hopeless, no attempt was made to reduce the disloca- 
tion. The limb was shortened one inch and a half, and the toes turned 
inwards. Extensive ecchymosis existed. On raising the gluteus 
maximus and medius, the naked head of the femur was found lying 
on the dorsum ilii with the ligamentum teres hanging to it, but par- 
tially torn off. Portions of the obturator externus pyriformis, and 
gemelli, were ruptured and lacerated. The capsule was torn through 
one-half of its extent. 

Dr. Fenner now proceeded to cut away the muscles, and when all 
the external muscles about the joint had been removed the thigh could 
not be brought down ; the iliacus internus and psoas magnus were 
then severed, which permitted it to descend a little, but the head could 
not be replaced ; the triceps adductor was then divided without effect. 
The ilio-femoral ligament was found tensely stretched. All the mus- 
cles between the pelvis and the thigh were then severed, and still it 
was impossible to reduce the dislocation; the head of the femur could 
not be forced back through the rent in the capsule from which it had 
escaped ; and it was not until the opening was enlarged from one-half 
to three-quarters of an inch, that the reduction was accomplished. 

Dr. Fenner infers that the capsule possesses sufficient elasticity to 
allow the small head of the femur to pass out through a lacerated 
opening, which might at once contract, so as to offer considerable resist- 
ance to its return, and that occasionally this is the true explanation of 
the difficulty in reduction. 4 Dr. Gunn, of Ann Arbor, Michigan, after 
repeated experiments made upon the dead body, concludes that the 
muscles offer no impediment whatever to the reduction, and that the 
" untorn portion of the capsular ligament, by binding down the head 
of the dislocated bone, prevents its ready return over the edge of the 
acetabulum to its place in the socket." 5 Dr. Moore, of Rochester, 
who has often repeated the same experiments upon the cadaver, de- 
clares, also, that in attempting to reduce the femur by extension alone 
he has constantly observed that the untorn portion of the capsule 
offered the main resistance, and that reduction could not be accom- 
plished until this was more completely broken up. 6 

1 Surgical Memoirs, by N. K. Smith, 1831. 

2 Buffalo Med. Journ., 1851. Trans. N. Y. State Med. Soc, 1852. 

3 London Med. Times and Gazette, Dec. 1865, p. 661. 

* New York Journ. Med., Sept. 1848, p. 268; from New Orleans Med. and Surg. 
Jour., Julv, 1848. 

s Ibid., Nov. 1853, p. 423 et seq. 
6 Ibid., Jan. 1855. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 677 

Busch, of Bonn, has arrived at similar conclusions ; l as also Profes- 
sors Roser, Weber, and Gelle. Professor Yon Pitha declares emphat- 
ically, that upon a knowledge of the ilio-femoral ligament is based the 
correct understanding of the various forms of hip-joint dislocations. 2 

But probably the most complete and conclusive defence of the views 
entertained by the gentlemen just referred to has been furnished by 
Dr. Henry J. Bigelow, the Pro- 
fessor of Surgery in Harvard FlG - 296 - 
University. In some respects, 
also, his opinions are wholly 
original. The following is a 
brief summary of these opinions. 

The ilio-femoral ligament, ' 
called by Dr. Bigelow the Y 
ligament (Bertin's ligament), 
the internal obturator muscle, 
and that portion of the capsule 
of the joint which is immediately 
subjacent, are alone required to 
explain, and are chiefly respon- 
sible for, the phenomena of the 
four regular dislocations. The 
pgular dislocations are those 
in which complete disruption 
of the ilio-femoral ligament has 
not taken place. 

The irregular dislocations are 
those in which the ilio-femoral 
ligament has suffered complete 
disruption. 

In reducing either of the reg- 
ular dislocations the limb must 
be flexed, in order to relax the 
ilio-femoral ligament; but if ■ 
other portions of the capsule 
are not sufficiently torn to admit the return of the head within its 
socket, it must be torn by circumduction of the limb. After flexion, 
and perhaps circumduction, the reduction may be completed by rota- 
tion, or by extension of the thigh at right angles with the anterior 
surface of the body. 

The dorsal dislocation owes its inversion to the external fasciculus 
of the ilio-femoral ligament. 

In the ischiatic dislocation, "dorsal below the tendon " (Bigelow), 
the head is arrested, in extension, by the tendon of the obturator and 
the subjacent capsule. 

The flexion and eversion of the limb in the thyroid dislocation are 
due to the ilio-femoral ligament. 




Ilio-femoral ligament. (Bigelow.) 



1 Year-Book of Med. and Surg, for 1864. Sydenham Soc. Publications; from 
Archiv. of Clinical Surgery, vol. iv, part i, Berlin, 1863. 

2 Von Pitha's and Biilroth's Surgery, vol. iv, 1865. 



678 



DISLOCATIONS OF THE THIGH. 



In the pubic dislocation the ascent of the limb is finally arrested by 
the ilio-femoral ligament. 

The conclusion at which we ought to arrive seems to be that, in 
some cases, the capsule being completely or almost completely torn 
away, the muscles offer the only resistance; and that according to the 



Fig. 297. 




Dislocation upon the dorsum ilii. (Bigelow.) 

exact position of the limb or degree of displacement, one or another 
set of muscular fibres will oppose the reduction ; and in other cases, 
the muscles being paralyzed by the shock, or by anaesthetics, the 
partially torn capsule, into which the head of the bone is received as 
in a button-hole, or the Y ligament, prevents its free return into the 
socket. 

Symptoms. — Sir Astley Cooper affirmed that the limb was some- 
times found shortened in this dislocation to the extent of three inches. 
Liston, B. Cooper, Gibson, and others, repeat the affirmation. Chelius 
places the extreme of shortening at two and a half inches ; Miller, at 
two inches ; while Malgaigne declares that he has never seen the limb 
shortened more than half an inch, and that in some cases it is not 
shortened at all, and the very opposite opinions entertained by other 
surgeons he attributes to errors in the measurement. I am certain, 
however, that Malgaigne has fallen into some error, and that, while 
the average shortening is about one inch or one inch and a half, it 
does occasionally reach three inches. 

The thigh is rotated inwards, adducted, and slightly flexed upon 
the pelvis. The great toe of the dislocated limb, when the patient 
stands erect (and in this position the examination ought, if possible, 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 679 



Fig. 298. 



to be made), rests upon the instep of the foot of the sound limb, and 
the knee touches the oppposite thigh near the upper margin of the pa- 
tella. It must not be supposed, however, that the position of the limb 
is in all cases precisely such as we have described. Indeed the degree 
of rotation, adduction, flexion, etc., will vary according as the head of 
the femur is more or less displaced, the capsule, including the liga- 
ments, more or less torn, or as it may be torn in its upper or lower 
margins, as the muscles may be ac- 
tually rent asunder, or only put 
upon the stretch, and perhaps also 
according to the amount of injury 
and consequent relaxation which 
they may have sustained from the 
shock. The thigh can be easily 
flexed ; adduction is more difficult, 
but abduction is almost impossible, 
except to a very limited extent: the 
body of the patient is a little bent 
forwards, the roundness of the hip 
is lost in consequence of the relaxa- 
tion of the gluteii muscles; the tro- 
chanter major is depressed, and 
approaches the anterior superior 
spinous process of the ilium ; and 
if the patient is not fat, and swell- 
ing has not already taken place, the 
head of the femur may be felt in its 
new position rotating under the 
hand when the limb is turned in- 
wards or outwards, but especially 
may it be felt when, by flexing or 
extending the limb, the head is made 
to move downwards and upwards, 
upon the dorsum ilii. . 

As we have already said, this ex- 
amination ought to be made, if possi- 
ble, in the erect posture; after which, 
it will be well to place the patient al- 
ternately upon his back, upon his 
sound side, and upon his belly, until 
the diagnosis is rendered complete. 

The differential diagnosis between dislocation upon the dorsum ilii 
and a fracture of the neck of the femur may be briefly stated as follows. 

In fracture, we may expect to find crepitus; the limb is in most cases 
mobile; the toes are generally turned out; the limb is shortened moder- 
ately or not at all ; the patient is sometimes able to walk for a short 
distance; fractures of the neck of the femur generally occur in advanced 
life. 

In dislocation, crepitus is not often present, and only when a frac- 
ture coexists; the limb is immobile, or nearly so; the toes are turned 




Dislocation upon the dorsum ilii 



680 



DISLOCATIONS OF THE THIGH. 



Fig. 299. 



in ; the limb is shortened more ; the patient is unable to bear the weight 
of his body upon his foot for one moment. Skey, however, says he has 
seen a patient with a recent dislocation, who walked one-quarter of a 
mile, to the hospital. I do not think any other similar case is upon 
record. Dislocations of the femur generally occur in middle life. 

I have been frequently told by persons who have called upon me 
with children suffering under hip-disease, that they had been informed 
the hip was out, and they expected me to reduce it. In two or three 
instances they have blamed their surgeons very much, because they 
had not detected the accident at the time of its occurrence. Norris, of 
Philadelphia, mentions an extraordinary example of this kind, as 
having been presented at the Pennsylvania Hospital, and which ought 
to serve as a sufficient warning to prevent similar mistakes in future. 
A lad, twelve years old, was brought to the hospital from a neighbor- 
ing State, who a short time previous had been suddenly attacked with 

lameness in his right limb, and which, by 
his friends, was attributed to some injury re- 
ceived in play. Two physicians, who had 
been called to see the boy, pronounced him 
to be laboring under dislocation of the hip, 
and had made two strong efforts with the 
pulleys, to reduce it; but, after causing great 
suffering, they gave up all hopes of ever re- 
placing the bone, and sent him to Philadel- 
phia. The symptoms were plainly those of 
hip-joint disease in its early stage. The at- 
titude was that assumed by those laboring 
under this affection ; the leg seemed length- 
ened, but a careful measurement showed that 
it was of the same length with the other ; the 
buttock was flattened, and the motions of the 
joint were tolerably free but painful. 1 

If the supposed dislocation occurs in a 
child, or in a person under ten years of age, 
we ought to take especial pains to ascertain 
that it is not a separation of the epiphysis, of 
which accident we have mentioned some ex- 
amples when speaking of fractures of the neck 
of the femur. 

Examples have occasionally been reported 
of " everted dorsal dislocations," in which 
most of the usual signs of a dorsal disloca- 
tion are present, except that the limb is 
everted, and sometimes slightly abducted. 
Bigelow attributes this condition to a rupture of the outer fibres of 
the ilio-femoral ligament, and he affirms that under these circumstances 
the limb may be found inverted, but it is also easily everted; the foot 




Everted dorsal dislocation. 
(Bigelow.) 



1 Norris, Amer. Journ. Med. Sci., vol. xxv, 



280. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 681 

may be slightly everted, it may lie flat upon the bed, or it may even 
point backwards. 

The treatment of the everted dorsal dislocation consists in reducing 
it first to an ordinary dorsal dislocation by flexion and rotation in- 
wards, aided by adduction, if necessary. 

Prognosis. — Boyer says the limb remains always weaker than the 
other, the round ligament never uniting completely; and that inflam- 
mation of the cartilages and synovial glands may ensue, ending in 
caries of the joint. Such results have, indeed, been occasionally met 
with, nor are examples wanting in w r hich more rapid inflammation, 
resulting in the formation of acute abscesses, has followed, but these 
are only rare accidents. In the large majority of cases the patients 
recover speedily, and in the course of a few w T eeks, or months at most, 
the limb seems to be as sound and as useful as before. 

Examples of non-reduction, however, from an error of diagnosis, or, 
what is more pertinent to our present purpose, from a failure to accom- 
plish the reduction where the attempt has been made, are numerous. 
Fortunately, Mr. Chelius, the author of a most excellent System of 
Surgery, to which we have already had frequent occasion to refer, has 
sufficient reputation, the world over, to enable him to bear a portion 
of these failures, without injury to himself or to the profession w 7 hich 
he so eminently adorns. We shall therefore make no apology for re- 
porting the following unsuccessful attempt to reduce a dislocation of 
the hip in which Mr. Chelius himself was the operator. 

On the 11th of June, 1851, John Mauren, a German, set. 19, called 
at my office and related as follows : " When ten years old, I fell from 
a tree, a height of six feet, and dislocated my left hip. I was then 
living twelve miles from Heidelberg, and I was immediately taken 
there, but I did not see Mr. Chelius until the next morning. He took 
me to the University, and, before the medical class, attempted to reduce 
it, but he could not. During several weeks following, he tried six 
times, using pulleys, etc., but he could never succeed." 

On examination, I found the limb shortened two inches, the head of 
the femur lying upon the dorsum ilii ; the knee was turned in, but the 
toes were inclined a little outwards. He was able to walk rapidly, of 
course with a manifest halt, yet without pain or discomfort. 

Treatment. — Regarding dislocations of the femur upon the dorsum 
ilii as the type of all the coxo-femoral dislocations, the remarks which 
we shall make under this section may be considered applicable, with 
only certain qualifications, to all the others. 

We shall arrange the various methods of reduction which have 
been employed by surgeons, under two principal heads, namely,, manip- 
ulation and extension. It is not possible, however, to classify rigidly 
the different procedures, so as to bring them under these two simple 
divisions, without some violence ; since neither manipulation nor ex- 
tension has usually been employed alone, but almost always some 
degree of extension has been recommended in connection with the 
manipulation ; if not in the first instance, at least in the event of the 
failure of manipulation alone ; while, on the other hand, extension is 
seldom if ever practiced without manipulation. We intend, then, to, 

44 



682 DISLOCATIONS OF THE THIGH. 

imply by these designations respectively, that either manipulation or 
extension has constituted the prevailing feature in the treatment. 

Reduction by manipulation dates from the earliest records of our 
science. Says Hippocrates : " In some the thigh is reduced with no 
preparation, with slight extension directed by the hands, and with 
slight movement; and in some the reduction is effected by bending the 
limb at the joint and making rotation." 1 

Richard Wiseman, who wrote in 1676, speaks as follows: "If the 
thigh-bone be luxated inwards, and the patient young and of a tender 
constitution, it may be reduced by the hand of the chirurgeon, viz., he 
must lay one hand on the thigh, and the other on the patient's leg, and 
having somewhat extended it toward the sound leg, he must suddenly 
force the knee up toward the belly, and press back the head of the 
femur into its acetabulum, and it will snap in. For there is no need 
of so great extension in this kind of luxation ; for the most consider- 
able muscles being upon the stretch, the bowing of the knee as afore- 
said reduceth it ; yet in rough bodies it may require stronger exten- 
sion." 2 

Richard Boulton repeated, in 1713, almost the same instructions, 
affirming that this plan was applicable especially to dislocations in- 
wards, in the case of " young and tender children." 3 

In 1742 Daniel Turner declared that he had reduced three disloca- 
tions of the hip, one of which was a backward dislocation, by a method 
combining extension with manipulation, but alone "by the strength 
of the arm or without any other instrument." Extension and counter- 
extension being made by assistants, and " as soon as the surgeon per- 
ceives the bone moving out," says Turner, "let him take his opportu- 
nity, giving orders to the extenders below suddenly to lift up the 
patient's thigh toward his belly, pressing with his hands, either to the 
right or left, as the situation of the same requires, and therewith force 
back its head toward the acetabulum, whereunto it will, flipping over 
the tip of the cartilage, snap sometimes with a loud noise." 4 

Thomas Anderson, surgeon, of Leith, in Scotland, was called, in 
Sept. 1772, to see a man who had dislocated his left femur into the 
foramen thyroideum. When he arrived four other surgeons were 
present, and prepared to use the pulleys, which they did in his pres- 
ence several times, but to no purpose. After examining the limb care- 
fully, " I was convinced," says Mr. Anderson, " that attempting the 
reduction in the common method, with the thigh extended, was im- 
proper, as the muscles were all put on the stretch, the action of which 
is, perhaps, sufficient to overbalance any extension we can apply. But 
by bringing the thigh to near a right angle with the trunk, by which 
the muscles would be greatly relaxed, I imagined that the reduction 
might more readily take place, and with much less extension. 

1 "Works of Hippocrates, Syd. ed., vol. ii, p. 643. 

2 Eight Chirurgical Treatises. By Kichard Wiseman, Serjeant-Chirurgeon to 
King Charles II. London, 1676. Book vii, chap. viii. 

3 A System of Kational and Practical Surgery. By Richard Boulton. London, 
1713, p. 346. 

4 The Art of Surgery. By Daniel Turner. London, 1742, vol. ii, p. 339. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 683 

" When I made this examination, he was lying on a table on his 
back. I raised the thigh to about a right angle with the trunk, and, 
with my right hand at the ham, laid hold of the thigh, and made what 
extension I could. From this trial I found I could dislodge the head 
of the bone. At the same time that I did this, with my left hand at 
the head and inside of the thigh, I pressed it toward the acetabulum, 
while my right gave the femur a little circular turn, so as to bring the 
rotula inwards to its natural situation ; and on the second attempt it 
went in with a snap observable to the gentlemen standing around, but 
more so to the poor man, who instantly cried out he was well and free 
from pain. His knees could then be brought together; the legs were 
of the same length, and the foot in its natural situation. The knees 
were kept together for some time, with a roller, to confine the motion 
of the thigh ; and in three weeks he was at his work, without the least 
stiffness in the joint." 

Subsequently Mr. Anderson reduced by a similar method a dislo- 
cation upon the dorsum ilii in a child eight years old, and which had 
been out nineteen days. 1 

Says Pouteau, in a memoir on dislocations of the thigh upwards 
and outwards : " We observe then, first, that the thigh ought to be 
flexed to a right angle with the body during the extension and coun- 
ter-extension ; second, that we ought to rotate the thigh from within 
outwards, when the extension appears to be sufficient ; third, that this 
position puts into relaxation, as much as possible, the triceps and 
gluteal muscles, which oppose the chief resistance to the extension, 
thus saving the patient from excessive pain ; fourth, that the flexion 
of the thigh places the head of the bone in the best position for a 
return to the cotyloid cavity during extension; fifth, that feeble ex- 
tension suffices for the reduction, because all of the muscles of the 
thigh are relaxed." 2 

On the 7th of January, 1811, Dr. Philip Syng Physick, of Phila- 
delphia, reduced an outward dislocation of the hip, after extension had 
failed, by flexing the thigh to a right angle with the body, and then 
giving to the limb an "outward circular sweep." 3 

So early as 1815, and perhaps much earlier, Nathan Smith, Professor 
of Surgery in the New Haven Medical College, taught that the only 
correct mode of reducing a dislocation upon the ilium was to flex the 
leg upon the thigh, the thigh upon the pelvis, and then to carry the 
limb diagonally to the opposite side, from whence it was to be brought 
outwards and downwards; 4 and in 1824, Dr. Smith, being under oath, 
affirmed as follows: "I do not think that the mechanical pow r ers, such 
as the wheel and axle, or the pulleys, are necessary to reduce a dislo- 
cated hip, or any other dislocation." He further adds that he once 
reduced a dislocation upon the dorsum ilii after he had pulled in every 
direction but the right, " by carrying the knee towards the patient's 

1 Anderson, Medical Commentaries, Edinburgh, 1776, vol. ii, pp. 261-4. 

2 Vidal (de Cassis) ; from GEuvres posthumes de Pouteau, Paris, 1783. 

3 Physick, Dorsey's Surg , 1813, vi, p. 242 Mem. of Nathan Smith, 1831, p. 172. 
Phelps's paper in Trans New York State Med. Soc, 1856, p^ 169. 

4 Trans. N. H. State Med. Soc, 1854, p. 55. 



684 DISLOCATIONS OF THE THIGH. 

face." 1 Subsequently the son of Dr. Smith, Nathan R. Smith, the 
present distinguished teacher of surgery in the Medical College at 
Baltimore, gave a more full account of his father's method, illustrating 
his views of the pathology of these dislocations, and the mechanism 
of their reduction, by several drawings. It must be noticed, however, 
that Dr. Nathan Smith left no written explanation of his views and 
practice, except that which is to be found in the affidavit already 
quoted, and that the account published by his son is from memory, 
and it is given as follows : " The patient being prepared for the oper- 
ation by whatever means may be deemed necessary, may be placed in 
an attitude convenient for the operation, with the body securely fixed, 
by placing him in the horizontal posture, on a narrow table covered 
with blankets, and on the sound side. To the table his body should 
be firmly fixed, and this can be conveniently done by folding a sheet 
several times, lengthways — then applying the middle of the broad 
band thus made to the inner and upper part of the sound thigh — 
carrying its extremities under the table, crossing them beneath it, and 
then carrying them obliquely up and crossing them firmly over the 
trunk, above the injured hip. The ends may then be secured beneath 
the table. To support the trunk the more firmly, a pillow may be 
placed on each side of it upon the table, and be included in the band- 
age. Should the operator design to employ any degree of extension, 
a counter-extending band may be placed in the perineum, and carried 
up to the extremity of the table, be fixed to some more firm body, or 
held by the hands of assistants. 

"The operator now standing on the side to which the patient's back 
presents, grasps the knee of the dislocated member with his right hand 
(if the left femur be dislocated — vice versa, if the right), and the ankle 
with the left. The first effort which he makes is to flex the leg upon 
the thigh, in order to make the leg a lever with which he may operate 
on the thigh-bone. The next movement is a gentle rotation of the 
thigh outwards, by inclining the foot toward the ground, and rotating 
the knee outwards. Next the thigh is to be slightly abducted by press- 
ing the knee directly outwards. Lastly, the surgeon freely flexes the 
thigh upon the pelvis by thrusting the knee upwards toward the face 
of the patient, and at the same moment the abduction is to be increased. 

" Professor N. Smith regarded the free flexion of the thigh upon the 
pelvis as a very important part of the compound movement. He 
believed that it threw the head of the bone downwards, behind the 
acetabulum, where the margin of the cup is less prominent, and over 
which, therefore, the abductor muscles would drag it with less difficulty 
into its place. 

" The operator may slightly vary these movements, as he increases 
them, so as to give some degree of rocking motion to the head of the 
os fern oris, which will thereby be disengaged with the more facility 
from its confined situation among the muscles." 2 

1 Report of the Trial of an Action for Malpractice. Lowel v. Faxon and Hawks, 
Machias, Maine, 1824; also Buff. Med Jour., vol. xiii, p. 515. 

2 Medical and Surgical Memoirs, by Nathan Smith, late Prof, of Surgery, etc., 
in Yale College. Edited by Nathan R Smith, Professor of Surgery in Univ. of 
Maryland. Baltimore, 1831, pp. 1(33-182. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 685 

Dr. Luke Howe, of Boston, who was a pupil of Nathan Smith's, 
gives the following account of the method practiced by him success- 
fully, about the year 1820, and which method, he says, was recom- 
mended by his preceptor : " The patient was permitted to lie on his 
back on the bed where I found him, the knee of the luxated limb 
turned in and over the other. I raised the knee in the direction it in- 
clined to take, which was toward the breast of the opposite side, till 
the descent of the head of the bone gave an inclination of the knee 
outwards, when I made use of the leg, being at right angle with the 
thigh, as a lever to rotate the latter and turn the head of it inwards. 
It then readily returned to its socket, with an audible snap. During 

Fig. -300. 




Nathan Smith's method of reduction by manipulation. (From Smith's " Memoirs.") 

this operation, the two assistants who had been placed to make the 
lateral extension and counter-extension, if ultimately required, were 
directed to draw moderately at their towels. How much of the success 
of the operation is to be imputed to their extension, and the rotation 
of the thigh by the leg, I am unable to determine ; but as Dr. Smith 
succeeded without the aid of either, and as the head of the femur 
seemed to descend by an easy and natural process, I am inclined to 
believe that all that is necessary, in such cases, is to elevate the knee, 
when the ilium, the muscles attached to it, and perhaps the ligament, 
become the natural fulcrum, over which the thigh, as a lever, acts to 
bring the head down and inwards into the socket." 1 

1 Howe, Boston Med. and Surg. Journ., vol. xxii, p. 249, May, 1840. 



686 DISLOCATIONS OF THE THIGH. 

Kluge, in 1825, combined moderate extension with manipulation, 
by flexing both the leg and thigh, while at the same moment the thigh 
was abducted and the knee rotated . inwards. 1 Wathman, in 1826, 
directed that in this dislocation the limb should be seized by the knee 
and ankle and slowly lifted forwards until it came to a right angle 
with the long axis of the body ; when, if the outward " self-twisting 
of the thigh" occurs, "which cannot be prevented by fast holding," 
the movement of the head of the bone is declared, and it will only 
remain for the surgeon to let down the thigh gradually upon the bed 
so that the two limbs will come side by side, and the reduction will be 
accomplished. 2 

Rust recommended also, in 1826, a similar plan, combining mode- 
rate extension by the hands, with flexion and abduction of the thigh. 3 

Colombat, whose opinions date from 1830, suggested that the patient 
should lay himself forwards upon a bed or table, no higher than his 
hips, with the sound leg and foot resting upon the floor, and that then 
the surgeon seizing the foot with one hand, so as to flex the leg, should, 
with the other hand, exercise a moderate degree of extension, and at 
the same time move the limb to the right or to the left, backwards and 
forwards, in order to disengage the head of the femur ; and, finally, 
that he should communicate to the thigh a sudden movement of cir- 
cular rotation, either from within outwards, or from without inwards, 
as the surgeon may choose. 4 

Collin states that, in 1833, he had reduced four dislocations of the 
hip by a method very similar to this recommended by Colombat. 5 

Dr. William Ingalls, of Chelsea, Mass., reduced a compound dislo- 
cation of the femur, in which the head of the bone rested upon the 
pubes, after an unsuccessful attempt had been made to reduce it by 
extension. " An assistant, taking the ankle of the dislocated limb in 
his right hand, and placing his left in the ham, bent the leg at right 
angles upon the thigh, and the thigh upon the pelvis, then lifting with 
a power little more than sufficient to elevate the whole limb, he carried 
it to its greatest state of abduction, at the same time rotating the femur 
inwards, while Dr. Ingalls passed his thumb through the wound, and 
pressing upon the head of the femur, directed it toward the acetabulum. 
At this moment he directed the limb to be forced toward its fellow, by 
which the reduction was effected with the greatest possible ease and 
elegance." 6 

Similar methods of reduction, with only such slight variations as 
scarcely deserve a special notice, have been suggested and practiced 
from time to time by Palletta, in 1818 ; 7 Desprez, in 1835 ; 8 Vial, in 
1841 ; 9 Fischer, Mahr, and Clark, in 1849. 10 

1 Chelius's Surg., by South, Amer. ed\, vol. ii, p. 241. 2 Ibid., p. 239. 

3 Ibid., p. 241, note by South. 

4 Malgaigne, op. cit., vol. ii, p. 825. 

5 Ibid., p. 823. 

6 Ingalls, Bransby Cooper's ed. of Sir Astley's English ed., 1842, and Amer. ed., 
1852. 

7 Chelius's Surg. ; note by South. 8 Malgaigne. 9 Ibid. 
10 Dublin Med. Press, Dec. 3, 1851. New York Journ. Med., March, 1852. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 687 

In 1851, Dr. W. W. Reid, of Rochester, N. Y., published an account 
of the method practiced by himself successfully in three cases of dis- 
location upon the dorsum ilii, the first of which dated from the year 
1844. His method, as applied to a dislocation upon the dorsum ilii, 
consists in " flexing the leg upon the thigh, carrying the thigh over 
the sound one, upwards over the pelvis as high as the umbilicus, and 
then abducting and rotating it." l 

Dr. Markoe, of New York, adopts the same procedure, except that 
when the limb has been sufficiently flexed and abducted, he directs 
that the limb shall be gradually brought down, and he affirms that it 
is during this last manoeuvre that he has usually found the bone resume 
its place in the socket. 2 

Bigelow, of Boston, declares, as has already been stated, that in all 
the regular dislocations, that is to say, in all those dislocations in which 
the ilio-femoral ligament is not torn, the thigh must be first flexed, in 
order to relax this ligament, and then reduction may be effected by 
extension directly forwards, the thigh being at a right angle with the 
body, or by rotation. In some cases, where there is probably only a 
button-hole slit in the capsule, free circumduction may be required in 
order that the capsule may be torn more freely. 

Fig. 301. 




Relaxation of the ilio-femoral ligament by flexion. (Bigelo-w.) 

His method of reducing the dislocation upon the dorsum ilii, is to 
flex the thigh upon the abdomen, abduct and then rotate outwards ; 
or, to flex, then adduct and rotate a little inwards, to disengage the 
head of the bone from behind the socket, then abduct and pull directly 

1 Eeid, Buffalo Med. Journ., vol. vii, Aug. 1851, pp. 129-143. 

2 Markoe, New York Journ. Med., January, 1855. 



688 



DISLOCATIONS OF THE THIGH. 



upwards. When necessary, circumduction is practiced to lacerate the 
capsule more completely. 

Reduction by extension dates from a period equally early with re- 
duction by manipulation. Hippocrates recommended, when other and 
gentler means had failed, to make extension and counter-extension ; 
the extending bands being made fast above the knee and above the 
ankle, so as to distribute the points of pressure ; and the counter-ex- 
tending bands being secured around the chest under the armpits, and 
also, if thought necessary, in the perineum of the sound side. 



Fig. 302. 




Hippocrates's mode of reducing dislocations of the hip by extension. 

Among the methods recommended and practiced by Hippocrates, 
was sitting across the upper round of a ladder with a weight attached 
to the thigh of the dislocated limb ; or suspending the patient from a 
sort of gallows with the head downwards, and if the weight of the 
patient's own body proved insufficient, the surgeon might add his 
also ; a method which Hippocrates characterizes as " a good, proper, 
and natural mode of reduction, and one which has something of dis- 
play in it, if any one takes delight in such ostentatious modes of pro- 
cedure." 1 

With various modifications as to the position of the limb, and as to 
the points upon which the extending and counter-extending forces are 
to be applied, and with differently constructed appliances, surgeons 
jhave continued to employ extension down to this day. 

The great majority have regarded flexion of the thigh as essen- 
tial to success ; some holding the limb only slightly flexed, and others 
insisting that flexion should be increased to a right angle with the 
body. 

The French surgeons, including Boyer and Yidal (de Cassis), prefer 
generally to apply the extending bands to the feet, in order that the 
muscles of the thigh may not be stimulated to contraction by the pres- 
sure of the bandages. Mr. Skey adopts the same method. 

Sir Astley Cooper, Samuel Cooper, B. Cooper, Fergusson, Miller, 
Pirrie, Erichsen, and the English surgeons generally, make fast the 



1 Works of Hippocrates, Syd. ed., London, vol. ii, p. 641. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 689 

lacq above the knee. J. L. Petit and Duverney, among the French, 
and Dorsey, Gibson, with most of the American surgeons, recommend 
the same, but Gerdy seeks to multiply the points of application, and 
for this purpose secures the extending band to the whole length of the 
leg, and to a small portion of the thigh above the knee. 

The counter-extending bands are now almost universally made to 
operate against the perineum of the dislocated limb, but Roux, follow- 
ing the practice of Hippocrates, places it in the perineum of the sound 
limb. Gibson recommends the same practice. 

Lizars recommends that sometimes the reduction should be attempted 
by simply placing the heel in the perineum and making the exten- 
sion with the hands, very much as Sir Astley Cooper advises us to 
proceed in dislocations of the humerus. Morgan and Cock, of Guy's 
Hospital, have reduced six cases of dislocation of the hip-joint by 
placing the foot between the thighs, so that it pressed against the 
upper part of the dislocated bone, and thrust it away from the pelvis ; 
extension and rotation of the limb being made at the same time by 
assistants. 1 Three of these were examples of dislocation upon the 
dorsum ilii, two upon the pubes, and one into the foramen thyroideum ; 
and most of them had occurred in weak or elderly persons. 

Ambrose Pare was among the first to recommend the use of pulleys 
for the reduction of dislocations. Most surgeons since his day have 
employed them for the purpose of making extension more energetic 
and steady, and that it might be longer continued. Sir Astley Cooper's 
plan of procedure is as follows : 

The patient having been bled freely, and the muscles still farther 



Fig. 303. 




Keduetion of a dislocation on the dorsum ilii, by pulleys. (Sir Astley Cooper's method.) 

relaxed by nauseating doses of antimony and by the hot bath, he is to 
be placed on his back upon a table of convenient height between two 
staples ; a strong padded leathern girth or perineal band, constructed 
so as to receive the thigh, and to press at the same moment against the 
perineum and the outer surface of the pelvis, is then applied and made 
fast to one of the staples situated behind the patient in the direction of 



Cock and Morgan, Chelius, op. cit., vol. ii, p. 242, note by South. 



690 



DISLOCATIONS OF THE THIGH. 



the axis of the limb. A wetted linen roller is next to be tightly- 
applied just above the knee, and upon this a leathern strap is to be 
buckled, having two short straps with rings at right angles with the 
circular part; or, instead of this, a round towel made in the knot 
called the clove-hitch. The knee is to be slightly bent, but not quite 
to a right angle, and brought across the opposite thigh a little above 
the knee. The pulleys being now attached, the extension is to be 
commenced. 

A very simple and efficient mode of making the extension, if one 
has not the pulleys, is to employ for this purpose a small rope, the 
ends being tied together, and the rope being then doubled upon itself 
once or twice, so as to make four or eight parallel cords. The oppo- 
site ends of this bundle of ropes being made fast to the limb and the 



Fig. 304. 




Reduction of a dislocation on the dorsum ilii, by the Spanish windlass. (Gilbert.) 

staple, the extension is made by thrusting a stick through its centre 
and twisting it. 

I have several times had occasion to resort to this plan ; and indeed 
it has been for some time known and practiced among surgeons in this 
country, 1 having been first, according to Professor Gilbert, introduced 
by Fahnestock, of Pittsburg, Pa. 

Jar vis's adjuster, to which I have already made allusion when speak- 
ing of dislocations of the humerus, has been often used with success in 
dislocations of the hip as well as in dislocations of the shoulder. 2 Its 
power is equal to that of the pulleys, while the direction of the force 
can be varied with much greater ease. The most serious objections 
to the instrument, as employed for the reduction of dislocations, are 
its complexity and its expensiveness. 

Mr. Fergusson says that the Lancet for July 26th, 1845, contains a 



1 Gilbert, of Philadelphia, note to Pirrie's Surg. ; also Amer. Journ. Med. Sci., 
vol. xxxv, April, 1845. 

2 Crandall, Bost. Med. and Surg. Journ., vol. xxxix, p. 77; Atlee, Trans. Amer. 
Med. Assoc., vol. iii, 1850, p. 357. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 691 

description of a similar apparatus constructed by Coxeter at the 
suggestion of G. N. Epps ; l and L'Estrange, of Dublin, has invented 



Fig, 




Jarvis's adjuster applied for reduction of a dislocation of the hip. 

a " windlass " for making extension, with a " forceps," by which the 
extending power can be instantly disengaged. 2 Mr. Bloxham's " dis- 

Fig. 306. 




Bloxham's "dislocation tourniquet" applied for reduction of a dislocation on the pubes. 

location tourniquet" is also very simple, and Mr. Erichsen affirms that 
by it " any amount of extending force that may be required can be 
readily set up and maintained." 3 Sedillot, a French surgeon, has sug- 
gested that when pulleys are used, we should measure the exact power 



1 Fergusson, 4th Amer. ed., p. 200. 
3 Erichsen, Amer. ed., 1858, p. 242. 



» Ibid., p. 198. 



692 



DISLOCATIONS OF THE THIGH. 



employed in the reduction, by an ingeniously contrived apparatus 
called the dynamometer. 1 Such an instrument might occasionally be 
useful in preventing the application of excessive force, especially when 
the patient is under the influence of an anaesthetic. 

Finally, without attempting to determine the precise relative value 
of these different procedures, all of which claim for themselves the tes- 
timony of experience, we are prepared to admit that no one of them is 
without merit, and that each may in certain cases possess advantages 
over the others. Precisely what the cases are to which each individual 
method may be especially applicable, we believe it would be impossible 
to declare unless the cases were actually before us ; and even then it 
would probably be found difficult often to say which was the best until 
a fair trial of one or more, and a final success, had determined the ques- 
tion. The time has not yet arrived in which we may institute a rigid 
comparison between the relative merits of the two leading plans of re- 
duction, manipulation and extension, for while it is true that reduction 
by manipulation has been practiced from the earliest day, it is equally 
true that extension has been generally preferred and practiced by sur- 
geons in all ages. Indeed, it was not until Dr.* Eeid, of Rochester, 
again called the attention of the profession to this subject, illustrating 
his views by the results of several successful experiments and by inge- 
nious arguments, that reduction by manipulation could be said to have 
been fairly introduced as an established method of practice ; a large 
majority of all the cases upon record of reduction by manipulation 
having been reported since the year 1851, the period of Dr. Reid's first 
communication to the Buffalo Medical Journal. 

The following summary of a paper prepared by myself, with the view 
of determining, if possible, the relative value of the two methods, and 
exhibiting an analysis of sixty-four cases in which manipulation was 
employed, will enable the reader to form some estimate of the difficulty 
in which this subject is involved; and if it does not actually decide a 
moot-point, it will at least demonstrate that the method by manipula- 
tion is not without its hazards. 2 

" Of forty-one cases in which the fact is stated, twenty-eight were 
reduced on the first attempt, seven on the second, four on the third, 
and two on the seventh. In seven examples the head of the femur has 
been thrown from one position to another upon the pelvis, travelling 
from the dorsum of the ilium to the ischiatic notch, and from thence 
to the foramen ovale ; or directly from the dorsum to the foramen, and 
back again ; or in other directions, according to the character of the 
original dislocation ; in some instances these changes being made as 
often as seven times in succession. In the majority of cases no evil 
consequences seem to have followed upon these changes of position. 
One of my own cases will especially serve to show with what impunity 
sometimes these changes may be made. 



1 Amer. Journ. Med. Sci., vol. xv, p. 530. 

2 Reduction of Dislocation of the Femur by Manipulation. By the Author. 
Buffalo Medical Journal, Nov. 1857; Feb., March, June, 1859. With tables con- 
structed by my very intelligent pupil, Lucien Damainville. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 693 

"John Caswell, set. 28, was admitted to the Buffalo Hospital of the 
Sisters of Charity on the 13th of January, 1858, with a dislocation of 
the left femur upon the dorsum ilii, which had occurred six days be- 
fore. His own account of the accident was that he was standing at 
the bottom of a well, bent forwards until his body was at a right angle 
with his thighs, when a bucket holding five hundred pounds of earth 
fell upon his back and hips. No attempt had been made to reduce 
the dislocation. Five times in succession manipulation made by my- 
self failed, leaving the head of the bone each time upon the dorsum 
ilii ; the sixth attempt, made with the addition of moderate extension 
by the hands, threw the head into the foramen thyroideum. By re- 
versing the movements, it was easily replaced upon the dorsum ilii. 
The seventh trial was made in the same manner, except that when I 
supposed the head of the bone to be opposite the lower margin of the 
socket I did not permit the limb to turn either outwards or inwards, 
but while lifting at the knee with my hands, with sufficient power to 
raise his hips from the table, I brought the limb down gradually to a 
line parallel with the opposite, and thus finally the reduction was 
accomplished. No pain or inflammation followed, and in two weeks 
he left the hospital ; but whether he was able to walk or not at that 
time, I am unable to say." 1 

Since this paper was written, the following cases have come to my 
knowledge. December 9th, 1865, Dr. James B. Wood attempted, at 
the Bellevue Hospital, the reduction of a dislocation of the femur upon 
the dorsum ilii, of five months' standing, in a man sixty years of age, 
in the presence of Dr. Sayre, myself, and the class of medical students. 
The patient was under the influence of ether. Manipulation alone was 
employed. Probably half an hour had been consumed in the various 
efforts, when, at a moment when the thigh was being forcibly abducted, 
the neck was broken within the capsule, and very close to the head. 
I was able to feel the head of the bone distinctly, after the fracture, 
and to move it freely separated from the neck. 

Dr. David Prince, of Illinois, who was present at the time, informed 
me that he had himself fractured the neck of the femur in attempting 
the reduction of an ancient dislocation of the hip by manipulation. 

In Markoe's paper, published in the New York Journal for January, 
1855, several cases similar to that of Caswell are reported, in which 
the results have been equally fortunate ; but the «case mentioned as 
having been under the care of Dr. Post, had a more serious termina- 
tion. This patient, John Kelly, set. 21, had a dislocation into the 
ischiatic notch, and on the same day the reduction was attempted by 
manipulation. On the first trial the head of the bone was thrown 
into the foramen ovale ; and, after having been moved backwards and 
forwards between these two points several times, it was finally carried 
directly from the foramen ovale into the socket by manual extension 
applied in the ordinary way, but without pulleys. " In this case," 
says Markoe, " the cure was very slow, and he left the hospital with 
some degree of pain and swelling about the joint. I learned that an 

1 Buffalo Medical Journal, vol. xiii, p. 682. 



694 DISLOCATIONS OF THE THIGH. 

abscess formed in or about the joint, which was opened, and when 
saw him, a year after, there was every appearance of seated morbus 
coxa ri us." 

In Case 14, of Markoe's paper, the thigh was broken at the neck 
after manipulation had been employed, but while extension was being 
made by the hands, united with " a lifting outwards." Whether the 
fracture was due to the extension, or to the manipulation, seems not 
to be clearly determined. The dislocation had existed seven weeks 
when this attempt at reduction was made. 

Dr. Bigelow has reported a case of dislocation upon the dorsum, of 
six months' standing, in a man 23 years of age, which he attempted to 
reduce, and caused a fracture of the neck of the femur. His account 
of the manner in which the accident occurred is as follows : " I flexed 
the limb once slowly upward upon the abdomen — a movement which 
was attended with a continued fine crepitation about the hip." Upon 
examination, the head of the bone was found to be separated from the 
neck. 

Dr. Dawson has reported to the Cincinnati Academy of Medicine a 
case in which this accident occurred in his own hands. Captain Wil- 
liamson, a gentleman in middle life and fair health, was received at 
Dr. Dawson's clinic with a dislocation into the ischiatic notch of nine 
weeks' standing. He was placed under the influence of ether, and 
various methods of manipulation employed. At last "more force was 
used, the thigh was pressed forcibly across the abdomen," and this was 
followed by rapid circumduction. At the sixth repetition of this ma- 
noeuvre, the neck of the bone suddenly gave way. 1 

A lad, set. 15, fell through a hatchway, dislocating the left femur 
upon the dorsum ilii. The surgeon first called did not recognize the 
accident. April 29th, 1873, eight weeks and one day after, this patient 
was received into St. Francis Hospital, and reduction attempted by 
Drs. Rose and Lellman, both gentlemen of experience. It was re- 
duced (apparently) with ease, the patient being under the influence of 
ether. Extension, with a six-pound weight, was applied to the limb, 
in order to secure quiet, and three days later they found the bone 
out of place, and they repeated the attempt at reduction by manipula- 
tion. It was now ascertained that the neck of the femur was broken, 
but whether this accident happened in the first or second attempt is 
not quite certain. Two days later I saw the patient, and found the 
limb shortened one inch and a half, and rotated outwards when un- 
supported. The head of the bone could be felt on the dorsum. 

Dr. Rose informs me that Dr. Krakowizer told him that he had just 
met with the same accident. 

Assisted by my pupil, Mr. Hodge, I have also succeeded in collect- 
ing sixty-two cases of attempts at reduction by extension ; a great 
majority of which, we find, were reduced in the first trials ; but five 
cases of recent dislocation were not reduced until after several attempts 
had been made. 

In five cases the femur was broken. The first occurred in St. 

1 Dawson, The Clinic, Oct. 17, 1874. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 695 

Thomas's Hospital, London. Ben. Whittenburg, set. 40, was admitted 
Nov. 4, 1827, with a dislocation into the ischiatic notch, of twenty -two 
weeks 7 duration. After bleeding, etc., had been practiced, an attempt 
was made to reduce the bone by pulleys, in which the reporter pro- 
fesses to believe they were successful, but on the following day it was 
plainly enough not in place. Mr. Travers again resorted to extension, 
and while extension was kept up and the assistants were rotating the 
limb outwards, the neck of the femur gave way. 1 Malgaigne mentions 
a case in which, while he was himself directing the operation, the thigh 
was broken through its lower third. He was attempting to reduce the 
bone by extension, but it was not until he gave the signal for rotation 
outwards that the bone gave way. 2 Gibson says that Dr. Physick, at 
the Pennsylvania Hospital, while engaged in reducing a dislocated 
thigh by the pulleys, broke the femur in consequence of exerting too 
much force upon it in a lateral direction by an additional pulley ; and 
that a similar accident is supposed to have happened to Drs. Harris 
and Randolph in the same hospital, in the year 1838, while using the 
pulleys upon a boy twelve years of age; for during extension and 
counter-extension, at the moment of rotating the limb, and of drawing 
it forcibly outwards by a towel, a sudden crack was heard. 3 

The fifth case is related by Sir Astley Cooper as having occurred 
at the Brighton Hospital, under the care of Mr. Gwynne ; the dislo- 
cation was upon the dorsum ilii, and was supposed to have existed 
about one month. The neck of the femur was broken in the first 
attempt at reduction, and while the surgeon was making extension, 
with gentle rotation. 4 

Sir Astley says : " There are plenty of cases upon record, of fatal 
abscesses from violent attempts at the reduction of dislocated hips." 
We presume that this remark has reference to attempts at reduction 
by extension, since, in his day, this was almost the only mode in use 
among surgeons. He adds, moreover, that Mr. Skey has mentioned, 
in the Lancet, 5 a fatal case of phlebitis following protracted extension 
of the hip. 

Malgaigne has collected no less than eight similar examples, with 
several more in which serious consequences and even death followed 
promptly upon violent attempts at reduction by mechanical means. 6 

The head of the bone has been repeatedly thrown from the dorsum 
ilii into the ischiatic notch, and B. Cooper mentions a case in which 
the bone was carried from the foramen ovale into the ischiatic notch, 
from which latter position it could not afterwards be changed. 7 

As to the relative chances of failure by the two methods, the testi- 
mony of the recorded cases is equally unsatisfactory. Of the failures 
by extension, the experience of almost every surgeon, the journals, and 

i London Med.-Chir. Rev., Nov. 1828, p. 239. 

2 Malgaigne, op. cit., vol. ii, pp. 146 and 830. 

3 Gibson's Surgery, sixth ed., vol. i, p. 389. 

4 Sir Astley Cooper on Disloc., etc., Amer. ed., p. 88. 

5 Op. cit., vol. i, p. 767, 1840-41. Cooper on Disloc., p. 69. 

6 Malgaigne, op cit., vol. ii, p. 164 et seq. 

7 Sir Astley Cooper on Disloc. By Bransby Cooper, Amer. ed., p. 96. 



696 DISLOCATIONS OF THE THIGH. 

the treatises furnish a sufficient number of examples; while among the 
sixty-four eases of attempts at reduction by manipulation collected by 
me, and excepting the cases in which the bone was broken, only two 
were positive failures. It is somewhat remarkable, however, that these 
two cases occurred in the experience of the New York City Hospital ; 
and that they are taken from a total of fifteen, this being the whole 
number which had been treated by this method at the date of these ob- 
servations, in the New York Hospital. One had existed one month, 
and, after repeated trials by manipulation and frequent changes of posi- 
tion, it was finally reduced by pulleys. The other, a dislocation into 
the ischiatic notch, had existed only a few hours. At least seven or 
eight trials were made to accomplish the reduction by manipulation, 
but without success. The first attempt by extension failed also, but in 
the second attempt the femur was kept at a right angle with the body, 
and the bone was soon brought into its socket. 1 

We have in these two examples not only a record of failure by manip- 
ulation, but an equal record of success by extension ; while, on the 
other hand, we find in an analysis of the sixty -four cases, sixteen tri- 
umphs of manipulation over extension. 

We must not omit to mention, in order that the reader may form a 
just estimate of the value of these statistics, that the great majority, es- 
pecially of the cases treated by manipulation, have occurred in private 
practice, and it is unnecessary to say that such statistics do not furnish 
the most reliable basis for conclusions. As a general rule, unsuccess- 
ful cases are not published by private practitioners, but successful cases 
are pretty certain to be made known ; while, on the other hand, a series 
of cases furnished by any single hospital will generally be found to 
have given both unsuccessful and successful cases. The writer has 
heard lately of a complete failure to reduce by manipulation in a recent 
luxation of the hip, after repeated efforts on several successive days, and 
where skilful surgeons were in attendance ; but it is believed that no 
account of the result has been published. 

We have already called attention to the fact that, in the New York 
City Hospital, two of the fifteen cases reported were failures; a circum- 
stance of remarkable significance, especially when we consider the skill 
of the several gentlemen who were the operators in these cases ; and it 
plainly renders a new series of statistics necessary, drawn solely from 
the experience of one or more similar large establishments, before we 
shall be prepared to decide positively upon the relative value of the 
two procedures. 

Nevertheless, we shall not hesitate to express our present convictions 
upon this subject, reserving to ourselves the right of a change of opinion 
whenever the proofs shall warrant it. 

Manipulation, owing to the greater power which may be brought to 
bear upon the neck and head of the bone through the action of the 
shaft of the femur as a lever, is most liable to throw the head of the 
bone into new positions, and consequently most liable to rupture the 
various soft tissues about the joint, to produce inflammation, suppura- 

1 Van Buren, New York Med. Times, Jan. 1856, p. 126. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 697 

tion, and caries. For the same reason it is most liable, also, to fracture 
the neck of the femur. It is not certain in our mind but that, when 
the principles which control the reduction are more completely under- 
stood, these evils may be lessened; yet we can scarcely persuade our- 
selves that by any future observations the state of the question will 
ever be greatly changed. We cannot but think, also, that some con- 
clusions ought to be drawn from the circumstances that, since the time 
of Hippocrates to the present day, manipulation has been occasionally 
recommended and successful examples reported; the reduction being 
accomplished in most instances by processes identical, or nearly so, 
with those now adopted ; yet generally the writers appear to have been 
ignorant of what had been done before, and, indeed, they have gener- 
ally avowed their belief that the method suggested by themselves was 
altogether new and original. Possibly this slowness to establish, and 
total inability to sustain and perpetuate a reputation, was not the fault 
of the method, and had no relation to its failures. Until within a few 
years, the number of surgical books, and especially of medical journals, 
was comparatively very small, so that valuable truths often died with 
their discoverers, or were known and remembered only by a few; but 
it is possible, also, that it has a deeper significance, and that it implies 
some defect in the procedure, or serious danger, in consequence of which 
it has from time to time lapsed into desuetude and finally into complete 
oblivion. 

The rules which the author would give for the employment of ma- 
nipulation are very simple. 

The patient being laid on his back upon a mattress, the surgeon, as- 
suming that it is a dislocation upon the dorsum ilii, should seize the 
foot with one hand and the other he should place under the knee ; then, 
flexing the leg upon the thigh, the knee is to be carefully lifted toward 
the face of the patient until it meets with some resistance ; it must then 
be moved outwards and slightly rotated in the same direction until re- 
sistance is again encountered, when it must be gradually brought down- 
wards again to the bed. We do not know that the whole process could 
be expressed in simpler or more intelligible terms, than to say, that the 
limb should follow constantly its own inclination. 

All writers have united in the necessity of flexion ; and, indeed, 
with very few exceptions, the advocates of extension have insisted 
upon carrying the dislocated limb more or less across the sound one ; 
or of making the extension at right angles with the body. They 
have also been nearly unanimous in their statements that the thigh 
should then be abducted and finally brought down. Nathan Smith 
has added the injunction to rotate the shaft of the femur outwards, 
and to press gently upon the inside of the knee while the thigh is 
being flexed upon the body, so as to compel the head of the bone to 
hug the outer margin of the acetabulum and to prevent its falling 
into the ischiatic notch ; a suggestion which has been erroneously in- 
terpreted by some writers to mean that he would carry up the limb 
abducted, a thing which is simply impossible until the reduction is 
accomplished. In adopting this practice, however, we must not forget 
the danger which we incur when the limb is completely flexed, and 

45 



698 DISLOCATIONS OF THE THIGH. 

the head of the femur is below the edge of the acetabulum, of throw- 
ing it over into the foramen ovale. Dr. Nathan Smith has also noticed 
the advantage which sometimes may be gained by giving to the limb 
at this moment a slight rocking motion. 

These movements of the limb, with perhaps other slight modifi- 
cations, such as lifting the knee moderately or forcibly when the bone 
refuses to mount over the margin of the acetabulum, pressing with 
the hand or foot upon the pelvic bones, and violent circumduction, are 
all which have been usually practiced in successful manipulation. 

We repeat, however, that as a general rule, in the first trial, the 
knee must be carried only in those directions which offer no resistance, 
and these will be found almost always to be the same; the knee of the 
dislocated femur hanging over the sound one will be made easily to 
ascend to about a right angle with the body ; we can then carry it out- 
wards a short distance, probably not more than four or five degrees ; 
at this moment, frequently, the thigh will begin to rotate outwards of 
itself, and with considerable force, or, as Wathman says, " a self-twist- 
ing of the thigh occurs, which cannot be prevented by fast holding." 
When this action takes place, the reduction is immediately accom- 
plished ; and it is in fact at this moment, before the limb begins to 
descend, that the bone most frequently resumes its socket. If it does 
not, then as soon as the limb begins to fall the reduction occurs, gen- 
erally with a loud snap. It is pretty certain that this manipulation is 
to fail if the knee has descended more than a few inches without the 
reduction having taken place; and it will be better to repeat the ma- 
noeuvre at once, rather than to bring the limb completely down. 

Generally anaesthetics ought not to be employed, since the operation, 
if successful, is not usually painful, and we need that the patient should 
preserve his consciousness, in order to admonish us when we are using 
improper violence. It is probable, also, that the action of certain 
muscles sometimes affords material assistance in the reduction. If, 
however, the patient is very sensitive, or the parts about the joint are 
very tender, or manipulation without anaesthetics has failed, then cer- 
tainly these agents may be properly and advantageously employed. 

If we propose to attempt reduction by extension, it is no longer 
necessary to resort to the lancet, antimony, and the hot bath, as pre- 
liminary measures, since the muscles can be at once overcome by the 
much more certain and more powerful agents, chloroform, ether, etc. 

The method recommended by Sir Astley Cooper, and most often 
practiced by surgeons of the present day, is essentially as follows : 

The patient is placed upon a bed of suitable height, reclining on his 
back, but partly over upon the sound side. Observing now the line 
of the axis of the dislocated thigh, one strong staple is to be secured 
into the wall upon one side of the room, and another upon the opposite 
side, both of which shall correspond as nearly as possible with the line 
of the shaft of the femur. The staple in front of the body will be 
higher than the bed, and the staple behind will be, in the same pro- 
portion, lower than the bed. The limb being stripped, two pieces of 
strong factory cloth, each about four inches wide and two feet long, 
should be laid parallel with and on each side of the limb ; the centre 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 699 

of each strip being about opposite that portion of the thigh which is 
just above the two condyles. Over the centre of these strips, above 
the condyles and patella, a strong roller, three inches wide and at least 
three yards long, previously wetted in water, is to be turned as tightly 
as it can be drawn until the whole roller is exhausted ; the extremity 
of the roller being made fast with a needle and thread rather than with 
pins. The upper ends of the side strips are then to be brought down, 
and tied to the lower ends, forming thus two lateral loops, upon which 
one of the hooks of the compound pulleys is to be made fast, while 
the other hook is secured to the front staple in the wall. Instead of 
these rollers we may employ, if we choose, a leathern thigh-belt. For 
the purpose of counter-extension a sheet is folded diagonally, and its 
centre being applied to the perineum of the dislocated limb, the ends 
are tied firmly into the back staple. To prevent the body from moving 
laterally, under the action of the pulleys, one assistant should be seated 
upon the bed, with his back against the side and back of the patient, 
and his right arm thrown over the body; it is well also to station 
another beside the sound limb, so as to retain it also in its place upon 
the bed. Underneath the upper part of the dislocated limb a strong 
and broad bandage should be placed, of sufficient length to tie over 
the neck of the surgeon when he is standing about half bent over the 
body of the patient. 

Everything being arranged, and all portions of the apparatus having 
been sufficiently tested to make sure that nothing will give way during 
the operation, the anaesthetic is to be administered, and as the patient 
falls gradually under its influence, the action of the pulleys should 
commence, and be slowly but steadily increased; a third assistant 
managing the rope, so as to leave the surgeon unembarrassed, and able 
to direct his whole attention to the position of the trochanter major 
and of the head of the femur. In order to this, he should place one 
hand upon each of these prominences, and watch carefully their de- 
scent. 

The length of time which will be required to bring down the limb 
must differ greatly in different persons, according to the peculiar cir- 
cumstances of the case, and the condition, age, etc., of the patient ; but 
it must never be forgotton that a slow and steady action is much more 
effective than rapid and irregular tractions, and it is in this especially, 
rather than in the relative amount of power, that the pulleys possess 
always so great an advantage over the hands. 

When the surgeon finds that the head of the bone has nearly or 
quite reached the socket, if it does not take its place spontaneously, he 
may place his neck in the noose which passes underneath the thigh, 
and lift upwards and outwards, in order to raise the trochanter major, 
aud thus enable the head to rotate toward the acetabulum. It is in 
this part of the manoeuvre, and especially when at the same moment 
one of the assistants, after bending the leg upon the thigh so as to 
make of it a lever, has rotated the thigh outwards, that the fracture 
of the neck has generally taken place ; and we cannot be too cautious, 
therefore, particularly in old persons, not to bear very strongly upon the 
noose, nor to permit the assistant to rotate outwards with great force. 



700 



DISLOCATIONS OF THE THIGH. 



Fig. 307. 



If the bone does not enter the socket, we may increase the flexion, 
or suddenly release the tension, or, in fine, again resort to manipula- 
tion alone. 

When the reduction is accomplished, the patient should be laid 
upon his back, with the knees resting over a pillow, and tied together 
lightly with a towel or a strip of cotton cloth. In order also the more 
certainly to prevent a reluxation, the thigh of the dislocated limb 
should be gently rotated outwards, by which the head will be pressed 
forwards against the anterior portion of the capsule. 

Such an accident, however, as a recurrence of the dislocation, in the 
case of the femur, is exceedingly rare; and I should have deemed it 
altogether impossible, except as the result of considerable violence 
again applied, had not at least two examples been reported to us upon 
very excellent authority. Malgaigne says he has himself seen an ex- 
ample of reluxation upon the dorsum ilii, occasioned by an untimely 
movement ; l and Verneuil has seen, ten days after the reduction of a 
dislocation upon the ischiatic notch, the dislocation reproduced by a 
sudden effort of the patieut to sit up ; 2 indeed, it is when the limb is 
in a flexed position that the accident seems most likely to occur. 

Of course, in these remarks we mean to except those cases in which 

the upper margin of the 
acetabulum is broken off, 
and the head of the femur 
has consequently lost its 
natural support in this 
direction. 

The possibility of this 
accident is also confirm- 
ed by the examples of 
"voluntary" dislocations, 
which I shall relate in 
the last section of this 
chapter. 

The method of exten- 
sion recommended by Dr. 
Bigelow, namely, with 
the thigh at a right angle 
with the body, has already 
been referred to; and 
there is much reason to 
believe that, as a rule, it 
is preferable to extension 
as practiced by Sir Astley 
Cooper. Nearly all sur- 
geons, however, have rec- 
ognized the necessity of 
flexing the thigh in cer- 
tain cases. Dr. Bigelow suggests that where greater force is required 




Tripod for vertical extension. (Bigelow.) 



1 Malgaigne, op. cit., torn, ii, p. 830. 



2 Ibid., p. 840. 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 701 

than can be obtained by the usual methods, a tripod should be em- 
ployed, as shown in the accompanying woodcut. 

The following case, reported to me by Dr. X. Fanning, of Catskill, 
N. Y., illustrates the occasional necessity of resorting to extension, and 
is of special interest on account of the extreme youth of the patient. I 
have referred to the same case once before. 

A little girl, two and a half years old, was caught under a falling 
door on the 24th of May, 1867, but her parents suspected no injury 
beyond a severe bruise until ten days later, when they consulted Dr. 
Fanning. The left femur was then found to be dislocated upon the 
dorsum ilii. Dr. Fanning attempted first to reduce the dislocation by 
manipulation, but he failed. He then directed the father to make ex- 
tension by the legs, while the mother made counter-extension by seiz- 
ing the child under the arms, and thus he soon succeeded in effecting 
the reduction. 

§ 2. Dislocations Upwards and Backwards into the Great Ischiatic 

Notch. 

Syn. — " Upwards and backwards into the ischiatic notch ;" Sir A. Cooper. " Up- 
wards and backwards into the great sacro-sciatic notch;" Lizars. "Backwards 
into the sacro-sciatic foramen ;" S. Cooper. "Backwards into the ischiatic notch;" 
Liston, B. Cooper, Miller, Pirrie, Erichsen, Skey, Gibson. " Downwards and out- 
wards on the os ischium ;" Boyer, Dorsey. " Backwards and downwards into the 
ischiatic notch;" Chelius, Petit, Duverney. "Upon the ischium;" Bertrandi. 
" Sacro-sciatic ;" Gerdy. " Ischiatic ;" Malgaigne. " Dorsal below the tendon ;" 
Bigelow. 

Boyer considers this dislocation as only secondary upon a dislocation 
upon the dorsum ilii ; but it is very certain that it often occurs as a 
primary accident. Not unfrequently, also, what w T as primarily a dis- 
location into the ischiatic notch, becomes subsequently a dislocation 
upon the dorsum ilii. 

Causes. — A fall upon the foot or knee when the limb is very much 
in advance of the body ; or the fall of a heavy weight upon the back 
and pelvis when the thigh is nearly or quite at a right angle with the 
body. Indeed, the causes are very similar to those which produce dis- 
locations upon the dorsum ilii, except that it is necessary to suppose 
the limb in a position more nearly at a right angle with the trunk, at 
the moment in w^hich the force is applied. 

Pathological Anatomy. — Mr. Syme, who dissected the body of a man 
recently dead w^hose thigh had been dislocated into the ischiatic notch, 
found the glutseus maximus nearly torn asunder, the head of the femur 
being imbedded in its substance; the gluteus minimus, the pyriformis, 
and the gemellus superior lacerated; the capsular ligament extensively 
torn close to the edge of the acetabulum, and the round ligament com- 
pletely separated from the femur. The head of the femur was lying in 
the great ischiatic notch, upon the gemelli and the sacro-sciatic nerve, 
behind the acetabulum and a little above it ; being situated between 
the upper margin of the notch and the great sacro-sciatic ligaments. 1 
Figure 308 is a representation of this specimen. 

1 Amer. Journ. Med. Sci., vol. xxxii, p. 460. 



702 



DISLOCATIONS OF THE THIGH. 



Dr. Joseph (1 Hutchinson, of Brooklyn, N. Y., has reported an ex- 
ample of this dislocation in which death having occurred four days 
after reduction, he was able to ascertain the character of the lesions. 
By the courtesy of Dr. Hutchinson, I was permitted to be present at 



Fig. 



Fig. 309. 





Dislocation upwards and backwards into 
the great ischiatic notch. (A. Cooper.) 

this autopsy, and the lesions 
were found to be much the 
same as in the case related by 
Syme ; but the glutseus mini- 
mus was not torn, and there 
was added a laceration of the 
obturator externus. Dr. Lente 
has reported one other dissec- 
tion made after reduction. 1 

Dr. Bigelow speaks of a dor- 
sal (upon the ilium) disloca- 
tion as sometimes occupying a 
position as low as the upper 
portion of the^ ischiatic notch ; but the dislocation now under consider- 
ation he describes as that in which the head of the femur having been 
driven from its socket downwards and backwards, is subsequently, in 
the attempt to straighten the limb, carried upwards behind the socket 
until it is arrested by the strong tendon of the obturator internus, and 
the subjacent capsule. This is usually denominated "ischiatic;" but 

1 Lente, New York Journ. Med., Jan. 1851. 



Dislocation upwards and backwards, into the great 
ischiatic notch. 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 703 

as it is both behind and below the tendon, Bigelow calls it "dorsal 
below the tendon." 

Fig. 310. 




Internal obturator in its natural position. (Bigelow.) 



Fig. 311. 




Internal obturator in its new position. (Iscbiatic) " Dorsal below tbe tendon." (Bigelow.) 



704 



DISLOCATIONS OF THE THIGH. 




Dislocation upwards and backwards into the 
great ischiatic notch. "Below the tendon," 
when the patient is recumbent. (Bigelow.) 



Symptoms. — The position of the limb is in some cases nearly the same 
as in certain dislocations upon the dorsum. It is shortened usually 
about half an inch, the thigh being flexed upon the body, adducted, 
and rotated inwards; but the flexion is often less than in dislocations 

upon the dorsum, while, on the other 
fig. 312. hand, it is sometimes much greater. 

Generally it is such that, when the 
patient is standing, the end of the 
great toe of the dislocated limb 
touches the ball of the great toe of 
the sound limb. 

Bigelow observes that the extreme 
flexion which is sometimes found to 
exist, especially when the patient is 
in the recumbent position, is gener- 
ally due to the arrest of the head of 
the femur by the internal obturator 
and the subjacent untorn capsule. 
When the patient rises, the weight of 
the limb may force the head up be- 
hind the tendon of the obturator ; or 
if the limb is brought down with 
force, the tendon and capsule may 
give way and the head may ascend 
to any point upon the outer surface of the ilium, and in this way an 
ischiatic may be converted into an iliac dislocation. 

The head of the femur is sometimes distinctly felt in its new posi- 
tion, especially when the limb is moved upwards or downwards. The 
trochanter major is approximated toward the anterior superior spinous 
process of the ilium. 

Sir Astley Cooper remarks that this dislocation is the most difficult 
to detect, and Mr. Syme mentions a case in which the nature of the 
accident was overlooked by himself, and the thigh was not reduced 
until the thirteenth day j 1 and subsequently Mr. Syme has called at- 
tention to what he considers as one of the most important diagnostic 
marks — indeed, he says it is never absent, nor is it ever met with in 
any other injury of the hip-joint, " whether dislocation, fracture, or 
bruise f this is " an arched form of the lumbar part of the spine, 
which cannot be straightened so long as the thigh is straight, or on a 
line with the patient's trunk. When the limb is raised or bent up- 
wards upon the pelvis, the back rests flat upon the bed ; but so soon 
as the limb is allowed to descend, the back becomes arched as before." 2 
This position, assumed by the back when an attempt is made to 
straighten and depress the limb, is due to the action of the psoas 
magnus and iliacus internus. But, in addition to this valuable sign, 
the inversion of the toes, immobility of the limb, and the absence of 



1 Amer. Journ. Med. Sci., vol. xviii, p. 242. 

2 Amer. Journ. of Med. Sci., Oct. 1843, p. 461, from Lond. and Edinb. Month. 



Jour., July, 1843. 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 705 

crepitus, are generally sufficient in themselves to distinguish it from a 
fracture of the neck. Dr. Squires, of Elmira, X. Y., in a note ad- 
dressed to me in March, 1860, suggests, also, that in ancient cases the 
projection of the head of the femur may be felt by passing the finger 
into the rectum or vagina. In this way Dr. Sayre and myself deter- 
mined a dislocation into the ischiatic notch which had existed six 
months, in a boy twelve years old ; and Dr. Wood, with myself, diag- 
nosticated the same dislocation in a woman at Bellevue Hospital, which 
had existed four weeks, in the same manner. 

Prognosis. — I have seen two dislocations of this 'character which 
were not recognized by the surgeons at the time of the receipt of the 
injury, nor for some weeks afterwards. One was in a lad twelve years 
old, who was brought to me from an adjacent county in August, 1847. 
The accident had happened eight weeks before. His limb was short- 
ened one inch ; it was also forcibly adducted and rotated inwards. 
Dr. Colegrove, a very excellent surgeon, had made a thorough attempt 
to reduce the dislocation with pulleys a few days before he was brought 
to me, and I did not deem it advisable to subject him again to the trial. 
Notwithstanding the dislocation, his limb was quite useful. The second 
was in the case of the boy seen by Dr. Sayre and myself, to which I 
have just referred. 

Treatment. — In employing manipulation, we may follow, with only 
a slight modification, the directions already given in dislocations upon 
the dorsum ilii. We find the head of the femur lower, consequently 
the extent of the circuit to be described in the manoeuvre is diminished, 
but in other respects the processes are identical. 

We must not forget, however, that there is especial danger, while 
attempting to reduce this dislocation by manipulation, that the head of 
the bone will be thrown across into the foramen thyroideum. I have 
already mentioned one case occurring under the care of Dr. Post in 
the New York Hospital, in which the head of the femur, originally in 
the ischiatic notch, passed backwards and forwards between the ischi- 
atic notch and the foramen ovale many times, and which, although 
the reduction was finally accomplished, was followed by morbus coxa- 
rius. Parker mentions a second case in the same paper, 1 in which his 
first attempt to reduce by manipulation carried the head of the bone 
into the foramen ovale ; but the second attempt was successful. In 
Dr. Hutchinson's case, to which I have already referred, the first 
attempt at reduction was made without an anaesthetic, and by manipu- 
lation after the method described by Reid. The first two attempts 
failed, and in the third, the limb being jnore abducted than before, the 
head of the bone was thrown into the foramen ovale. By reversing 
the movements, it was replaced in the ischiatic notch ; and this change 
of position was made seven or eight times. The patient was now 
etherized, and the bone was lifted into its socket in the same manner 
which I have described in the case of Caswell. Malgaigne refers to a 
patient of Lenoir's and to another of his own, in which the head of 

1 Markoe's paper, N. Y. Journ. of Med., Jan. 1855. 



706 DISLOCATIONS OF THE THIGH. 

the bone was lodged under the margin of the acetabulum during the 
attempts at reduction. 1 

On the 23d of March, 1855, Charles McCormick, jet. 21, a laborer 
on the " State Line Railroad," was caught between two cars, with his 
back resting against one car, and his right knee against the other, the 
right thigh being raised to a right angle with his body. As the cars 
came together he felt a " cracking " at his hip-joint, and found him- 
self immediately unable to walk or stand. 

Two hours after the accident, assisted by my son Theodore, and 
Austin Flint, Jr., I examined the limb carefully, and made arrange- 
ments for the reduction with the pulleys, in case the attempt by ma- 
nipulation should fail. 

The patient lying upon his back, I seized the right leg and thigh 
with my hands, the leg being moderately flexed upon the thigh, and 
carried the knee slowly up toward the belly, until it had approached 
within twelve or fifteen inches, when, noticing a slight resistance to 
farther progress in this direction, I carried the knee across the body 
outwards, until I again encountered a slight resistance, and immedi- 
ately I began to allow the limb to descend. At this moment a sudden 
slip or snap occurred near the joint, and I supposed reduction was ac- 
complished ; but on bringing the limb down completely, I found it 
was still in the ischiatic notch. I think the head had slipped off from 
the lower lip of the acetabulum, after having been gradually lifted 
upon it. 

Without delay I commenced to repeat the manipulation, and in pre- 
cisely the same manner. Again, at the same point, when the limb was 
just beginning to descend, a much more distinct sensation of slipping 
was felt, and on dropping the limb it was found to be in place and in 
form, with all its mobility completely restored. 

No anaesthetic was employed, and no person supported the body or 
interfered in any way to assist in the reduction. No outcry was made 
by the patient, yet he informed me that the manipulation hurt him 
considerably. The amount of force employed by myself was just suffi- 
cient to lift the limb, and the time occupied in the whole procedure 
was only a few seconds. 

After the reduction he remained upon his back, in bed, eleven days, 
in pursuance of my instructions. At the end of this time he began to 
walk about, but was unable to resume work until after eight weeks or 
more. It is probable that he could have walked immediately after the 
reduction, without much if any inconvenience, so trivial was the in- 
flammation which resulted from the accident. He never complained 
of pain, but only of a slight soreness back of the trochanter major, 
near the head of the bone. This soreness continued several weeks, 
and was especially present when he bent forwards. After the lapse of 
four months, when I last saw him, he occasionally felt a pain at this 
point in stooping, but the motions of the joint were free ; he walked 
rapidly and without halt. 

1 Malgaigne, op. cit., torn, ii, p. 839. 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 707 

If the reduction is attempted by extension, we ought to remember 
that the head of the bone lies more behind than above the socket, and 
that it is not requisite to carry it downwards so much as forwards ; 



Fig. 313. 




Reduction of dislocation upwards and backwards into the great ischiatie notch, by extension. 
(Sir Astley Cooper's method.) 



and especially that it must mount over the most elevated margin of 
the socket, in order to resume its position. The extension ought, 
therefore, to be made at a right angle with the body, as the following 
case will illustrate : 

John Hebden, set. 40, was sitting with his legs hanging over the 
dock, when his left knee was struck by a ferry-boat, dislocating the 
head of the femur into the ischiatie notch. I found him at Bellevue 
Hospital on the following morning, about twenty hours after the acci- 
dent, September 29, 1866. In the recumbent posture the limb was 
pretty strongly adducted and slightly rotated inwards. It was short- 
ened three-quarters of an inch. In the erect posture both adduction 
and inward rotation were very slight. 

Having etherized him, I made three separate attempts at reduction 
by manipulation, but failed. I then made extension in the following 
manner : The patient resting upon his back, I stood astride his body, 
and clasping my hands under the knee, I pulled directly upwards, 
while an assistant held down the pelvis. I did not feel the bone resume 



708 DISLOCATIONS OF THE THIGH. 

its place, nor was I aware that reduction was accomplished, but when 
I let the limb down the bone was found to be in its socket. 

Two or three minutes later, and before the patient had recovered 
from the effects of the ether, I raised the knee, to indicate to some 
young men, who had just come in, how the dislocation had been re- 
duced, when it slipped out again, with a sudden jerk and a grating 
sensation. This sensation I had felt once or twice before while ma- 
nipulating. It was scarcely as rough as the crepitus of a fracture, and 
it probably indicated that the cartilaginous margin of the acetabulum 
had been broken off. 

The limb was now brought down to the bed, and it was found to be 
in the same position as before reduction was attempted. Standing 
again over the patient, and placing my hands under the knee, I pulled 
upwards, and the head resumed its place; this time with a sudden jerk 
and with the same rough sensation. The limb was then placed in the 
extended position and secured by a long splint, which was not removed 
until the eleventh day. 

The facility with which the reluxation took place in the preceding 
case will sufficiently explain what happened in the following case on 
the tenth day after reduction, and on account of which I was subse- 
quently consulted. 

William Milne, set. 19, of Orleans County, N. Y., was thrown from 
a wagon May 13, 1858, dislocating his left femur into the ischiatic 
notch. Dr. Watson, of Clarendon, Orleans County, was consulted 
within three hours. Drs. Wood and Tafft were also present. Dr. 
Watson laid the patient on his back, and without anaesthetics reduced 
the dislocation by manipulation. The bone was felt distinctly as it 
slipped into its place, and the limb immediately resumed its natural 
position and length, as all the surgeons present affirm. He was soon 
out of the house oh crutches, and on the eleventh day went in bathing. 
When he came out of the water he complained of his hip, and on the 
following day it was seen to be shortened. Subsequently it was ex- 
amined by several surgeons, all of whom pronounced it dislocated. 
An attempt was then made to reduce the dislocation by Jarvis's ad- 
juster, but without anaesthesia, as the patient refused to be rendered 
insensible. The attempt did not succeed, and the father brought an 
action against Dr. Watson in the Supreme Court of Orleans County, 
Judge Davis presiding, for September, 1858. The prosecutor failed to 
appear, and Dr. Watson, the defendant, took judgment by default. 

Lente relates a case in which, extension being employed, the cord 
was suddenly cut while the limb was abducted and rotated outwards, 
when the head of the femur left the ischiatic notch, and rose upon the 
dorsum ilii, assuming a position directly above the acetabulum, and 
below the anterior superior spinous process ; and from which position 
it was subsequently, with great difficulty, returned to the socket. 1 

1 Lente, New York Journ. Med., November, 1850, p. 314. 



INTO THE FORAMEN THYEOIDEUM. 709 



§ 3. Dislocations Downwards and Forwards into the Foramen 
Thyroideum. 

Syn. — "Downwards into the foramen ovale;" Sir A. Cooper. "Downwards 
into the obturator foramen;" Lizars. " Downwards and forwards into the foramen 
obturatorium ;" B. Cooper. " Inwards and downwards into the oval hole ;" Chelius. 
"Downwards and forwards into the foramen ovale;" Pirrie. " Downwards and 
inwards;" Boyer. "Subpubic;" G-erdy. " Ischio-pubic ;"' Malgaigne. 

Causes. — In order to produce this dislocation the limb must be, at 
the moment of the receipt of the injury, in a position of abduction. 
Perhaps most often it is occasioned by the fall of a heavy weight upon 
the back of the pelvis when the body is bent and the thighs spread 
asunder. 

Pathological Anatomy. — The capsule gives way upon the inner side 
especially ; the round ligament is torn from its attachment, and the 
head of the femur, pressing forwards and downwards, finds a lodg- 
ment upon the obturator externus muscle, over the foramen thyroi- 
deum. 

Symptoms. — The thigh is lengthened from one to two inches, ab- 
ducted and flexed, the body being also bent forwards or flexed upon 
the thigh. -The dislocated limb is advanced before the other, and the 
toes generally point directly forwards, but they may incline either out- 
wards or inwards. The hip is flattened or depressed ; the long adduc- 
tors are felt tense upon the inside of the limb ; the trochanter major 
is less prominent than upon the opposite side ; and the head of the 
bone may sometimes be felt in its new position. The lengthening of 
the limb alone is sufficient to distinguish this accident from a fracture 
of the neck. 

The flexion and abduction are due in some measure to the tension of 
the psoas magnus and iliacus internus, and perhaps to a similar con- 
dition of other rotators and flexors ; but, according to Bigelow, the 
ilio-femoral ligament offers the chief resistance, and constitutes the 
chief impediment to the restoration of the bone. 

Treatment. — It is pretty certain that in the following example there 
was a spontaneous reduction, or rather, I ought to say, an accidental 
reduction of a dislocated femur from the thyroid foramen. Perhaps 
it was only an example of a partial luxation ; of which species of for- 
ward luxation I shall hereafter relate another case as having come 
under my own notice. 

Jacob Lower, set. 10, fell from a tree, a height of about twelve feet, 
to the ground. It is not known how he struck. He became imme- 
diately quite faint, and w 7 hen he had partly recovered, he attempted to 
get up, but could not. He said his leg was broken, and cried out lustily 
whenever it was moved. The father arrived in about an hour, and 
found him still lying on his back where he had fallen, with his right leg 
carried away from the other, and turned outwards. He lifted him up to 
place him in a small hand-wagon, which was long enough for his body, 
but only one foot and a half in wddth. Finding that his right leg was 
so much abducted as to prevent his being laid in so narrow a space, he 



710 DISLOCATIONS OF THE THIGH. 

seized upon it, and with some force pressed the knee inwards across 
the opposite leg, when suddenly it resumed its position with a loud 
snap like a "cannon." I use the language of the father. On the 
following day I examined the limb carefully, and found its motion 

Fig. 314. Fig. 315. 





Eelations of the ilio-femoral ligament to the thyroid 
dislocation. (From Bigelow.) 

free. He was, however, vomiting the 
contents of his stomach, and passing 
blood from the bladder quite freely. 
The vomiting soon ceased, but the 
haemorrhage from the bladder con- 
tinued three Or four days. On the Dislocation downwards and forwards into 
..it t -Mi , 1 ,1 the foramen thyroideum. 

ninth day he walked out, and on the 

twelfth he was seen climbing upon the 

top of a house. I saw him again after the lapse of a year, and found 

that he was still complaining of an occasional soreness in the region of 

the hip-joint. 

If we attempt to reduce by manipulation, it will be proper to follow 
the same rule which we have stated as applicable to dislocations back- 
wards, namely, to carry the limb, in the first instance, only in those 
directions in which it is found to move easily. Instead, therefore, of 
holding the leg in a position of adduction while the thigh is flexed upon 
the abdomen, it will be necessary to carry it up abducted ; and when 
the further progress of the knee toward the belly is arrested, the limb 



INTO THE FORAMEN THYEOIDEUM. 



711 



must be moved inwards, and finally brought down adducted. When 
the knee is about opposite the pubes, or a little lower, in its descent, 
the femur should be gently rotated inwards, for the purpose of direct- 
ing the head toward the acetabulum. The reduction may also be some- 
times facilitated by lifting the head of the bone with the aid of a band 
passed under the upper portion of the thigh and over the shoulder of 
an assistant ; by giving to the shaft of the femur a slight rocking mo- 
tion when it is about to enter the socket; and also by pressing with the 
hand against the head of the bone, or by lifting at the knee moderately. 
In one of the examples recorded by Markoe (Case 8), the reduction 
was accomplished in the second attempt, by rotating the thigh inwards 
just as the thigh had descended below a right angle with the body, 
in the manner which we have above directed ; but in a second example 
(Case 9), a similar manoeuvre carried the head across into the ischiatic 
notch, while the reduction was finally accomplished by rotating the 



Fig. 316. 




Reduction of thyroid dislocation by manipulation. (From Bigelow.) 



thigh outwards, and at the same moment adducting the limb strongly 
in a direction which carried the knee behind the other one. Markoe 
concludes that the latter mode is preferable, because it will throw the 
head of the bone a little upwards as well as outwards ; in which direc- 
tion it will find a more gently inclined plane toward the socket. He 
admits, however, that both methods may accomplish the same result. 
But I am quite certain that the method by rotation of the shaft of the 
femur inwards is in general most likely to succeed. In this way also, 



712 DISLOCATIONS OF THE THIGH. 

I think, both W. H. Van Buren, of New York/ and R. L. Brodie, 
of the U. S. Army, were successful; 2 it is the method preferred by 
Bigelow, who also recognizes the propriety of making outward rotation 
when inward rotation fails. " Flex the limb towards a perpendicular, 
and abduct it a little to disengage the head of the bone ; then rotate 
the thigh strongly inward, adducting, and carrying the knee to the 
floor." It is especially worthy of notice that Anderson, so long ago 
as 1772, in the case already quoted when we were considering the his- 
tory of reduction by manipulation, practiced successfully almost pre- 
cisely the same method. In one example mentioned by Markoe (Case 
7), it is pretty evident that the head of the femur was thrown into the 
ischiatic notch, by having flexed the thigh too much, so that "the 
knee touched the thorax." Indeed, it is questionable whether it will 
be best ever to bring the thigh much, if at all, above a right angle with 
the body, since any further flexion can only throw the head below the 
acetabulum, when in fact it is already too low. 

July 21, 1858, Nathaniel Smith, a painter by trade, set. 33, fell from 
the second-story window of the city post-office, Buffalo, upon a stone 
pavement, striking, as he believes, upon the inside of his right knee. 
I saw him within an hour, and found the right tibia partially dislocated 
outwards, the corresponding patella dislocated completely outwards, 
and the right femur in the foramen thyroideum. His thigh was forci- 
bly abducted, slightly rotated outwards, and lengthened, by measure- 
ment made from the pelvis to the ankle, one inch and a half. The 
distance from the anterior superior spinous process to the fold of the 
groin was ten inches, but upon the sound side it was only eight and a 
half. The head of the femur could be distinctly felt in front, just 
under the pubes. 

Having administered chloroform, I first reduced the tibia and the 
patella, then seizing the thigh and leg, I flexed the thigh upon the 
body, carrying the limb upwards abducted until it was nearly or quite 
at a right angle with the body, then inclining the knee slightly in- 
wards, I brought it down again, and when the thigh had nearly reached 
the bed, it fell into its socket with a dull flapping sensation. In every 
step of the procedure I followed the inclination of the limb. The 
recovery was rapid and complete. 

Sir Astley Cooper says that this dislocation is in general reduced 
very easily by the aid of pulleys ; at least if the accident is recent. 
He advises that the patient shall be placed upon his back, with his 
thighs separated as far as possible. The pulleys are to be made fast 
to a band drawn through the perineum of the dislocated limb, in a 
direction upwards and outwards; while a counter-band is to be passed 
around the pelvis through the band attached to the pulleys, and secured 
to a staple, or delivered to assistants placed upon the sound side of the 
body. When everything is arranged, the pulleys should be acted upon 
until the head of the femur is felt moving from the foramen ovale ; at 

1 W. H. Van Buren, New York Med. Times, Jan. 1856, p. 127. 

2 R. L. Brodie, Memphis Med. Recorder, Sept. 1857, p. 93; from Charleston 
.Med. Rev. 



INTO THE FORAMEN TH YKOIDEUM. 



713 



this moment the surgeon must pass his hand behind the sound limb, 
and seizing upon the ankle of the dislocated limb, adduct it forcibly, 
thus converting the limb into a lever of the first order. 

If the dislocation has existed some time, he recommends that this 
procedure shall be varied by placing the patient upon his sound side 
instead of his back, and attaching the pulleys perpendicularly over 



Fig. 317. 




Sir Astley Cooper's mode of reducing a recent luxation into the foramen thyroideum. 

the body. Sir Astley especially cautions us not to flex the thigh during 
these manoeuvres, lest we force the head of the bone backwards into 
the ischiatic notch, from whence he affirms that it cannot afterwards 
be returned to its socket ; but the experience of surgeons has since 
shown that this latter statement is incorrect, and that it may, in some 
cases, be afterwards reduced, although it has fallen into the ischiatic 
notch. Mr. Liston says that this accident happened to himself while 
attempting to reduce a dislocation of only a few hours' standing, in a 
young and powerful man, but he had no difficulty in returning it to 
its first position. 1 

Brain ard, of Chicago, reduced a dislocation of that form of which we 
are now speaking, after both the compound pulleys and Jarvis's adjuster 
had failed, by placing between the thighs a piece of wood wrapped 
about with several layers of a wadded quilt, and making use of this as 
a fulcrum upon which the thigh operated as a lever. The legs were 
simply pressed together, care being taken to keep the knees straight. 2 



1 Practical Sure:., Araer. ed., p. 93. 

2 Brainard, Northwestern Med. and Surg. Journ., 1852. 

46 



714 



DISLOCATIONS OF THE THIGH. 



The majority of surgeons of the present day place the limb in the 
flexed position before attempting to make traction. This may be done 
with the patient lying upon his back, and by the hands, alone, or with 
pulleys, or the patient may be placed in a sitting posture, and the ex- 
tension made at right angles with the body. In all of these attempts 
to reduce by traction, measures must be taken to secure immobility to 
the pelvis. 

May 23, 1868, a man, 40 years of age, was admitted to Bellevue, 
having a dislocation of the left femur into the foramen thyroideum, 

which had been caused six hours 
FlG - 318, before by the fall of a heavy 

weight upon his back while 
stooping. The limb was slightly 
abducted, and moderately flexed 
upon the pelvis, while he was 
lying upon the bed ; the position 
being that represented in Fig. 
315. There was a very marked 
depression in the situation of the 
trochanter major, and a fulness 
upon the inside of the limb, 
caused by the tension of the 
long adductors. 

The patient being under the 
influence of ether, the house- 
surgeon, Dr. E. D. Hudson, 
first attempted, under my in- 
struction, to reduce the disloca- 
tion by manipulation, flexion, 
and rotation, with adduction ; 
but failing in this, a folded sheet 
was placed in the perineum cor- 
responding to the dislocated limb, and committed to assistants, who 
were directed to pull upwards and outwards, the patient lying upon 
his right side, with his left thigh flexed to a right angle with his body. 
Dr. Hudson then passed a band under the upper part of the thigh and 
over his shoulders, lifting and pressing the knee forcibly inwards at 
the same time. In a few seconds the reduction was accomplished. 

After the reduction is accomplished, the patient should be laid upon 
his back in bed, but instead of rotating the limb outwards, as we have 
advised after a dislocation upon the dorsum ilii or into the ischiatic 
notch, it should be gently rotated inwards, and the knees thus bound 
together. 

§ 4. Dislocations Upwards and Forwards upon the Pubes. 

Syn. — "Upwards and forwards on the horizontal branch of the share-bone;" 
Chelius. " Forwards upon the pubes;" Pirrie. " On the body of the pubes, below 
the spine and transverse part of the bone;" Skey. " Sur-pubic;" Gerdy. "Ilio- 
pubic;" Malgaigne. 

Caicses. — This accident is generally occasioned by a fall upon the 
foot when the leg is thrown backwards behind the centre of gravity ; 




Effect of flexion upon the ilio-femoral ligament in 
the thyroid dislocation. (From Bigelow.) 



UPWARDS AND FORWARDS UPON THE PUBES. 715 

as in a fall from the back end of a wagon, the foot being instinctively 
thrown backwards in order to save the head; or it may happen to a 
person who, while walking, suddenly puts one foot into a hole, in con- 
sequence of which the pelvis advances, but the leg and upper part of 
the body incline forcibly backwards. Occasionally it has resulted from 
fall upon the back of the pelvis, or from a severe blow received upon 
the same part. A patient was admitted, under the care of Dr. Ure, 

Fig. 319. 




Specimen of dislocation upon the pubes, in St. Thomas's Hospital. (From Sir A. Cooper.) 

into St. Mary's Hospital, London, with a dislocation upon the pubes 
occasioned by swimming. His account of it was, that when in the 
act of " striking out " he felt a catch in the right groin which he 
thought was cramp, and that he was able to walk after the accident, 
but with a good deal of difficulty. The examination proved that he 
had a dislocation upon the pubes, which Dr. Ure easily reduced. 1 

Pathological Anatomy. — Sir Astley Cooper dissected the hip of a 
person whose thigh had been dislocated upon the pubes for some time, 
the true nature of the accident not having been at first recognized. 
The acetabulum was partly filled by bone, and partly occupied by the 
trochanter major, both of which were much altered in their form. The 
capsular ligament was extensively torn, and the ligamentum teres 
broken off completely. The head and neck of the femur had torn up 
Poupart's ligament, so as to penetrate between it and the pubes, and 
lay underneath the iliacus internus and psoas muscles; the anterior 
crural nerve was lying upon these muscles, over the neck of the femur. 
The head and neck were flattened and otherwise much changed in 
form. Upon the pubes a socket was formed for the neck of the thigh- 
bone, the head being above the level of the pubes. The femoral artery 

1 Medical News and Library, vol. xvi, p. 1 ; from Lond. Lancet, Nov. 7, 1857. 



716 



DISLOCATIONS OF THE THIGH. 



and vein were to the inner side. This specimen is still preserved in 
St. Thomas's Hospital. 

The head of the femur may be found lying far forward upon the 
pubes, as in Physick's case mentioned below ; or it may lie farther 
back, along the ilio-pubic margin, and rest below and in front of the 
anterior superior spinous process of the ilium. When the head rests 
directly below this process, the dislocation is considered anomalous 
or irregular, and this form will be considered hereafter as the " sub- 
spinous " dislocation. 

In the accompanying drawing the relation of the ilio-femoral liga- 
ment to the head and neck of the femur is shown, when the head 

ascends moderately upon the 
FlG - m pubes. The extreme displace- 

ment shown in the preceding 
illustration from Sir Astley 
Cooper is only possible where 
that portion of the capsule be- 
neath the obturator internus is 
torn, and perhaps the obturator 
itself. According to Bigelow, 
the ilio-femoral ligament and 
the psoas magnus and iliacus 
internus are then the only re- 
maining causes of eversion. 

Symptoms. — The thigh is 
shortened, abducted, flexed 
slightly, rarely extended, and 
rotated outwards. The tro- 
chanter major is lost, or nearly 
so, while the head of the bone 
may be generally felt like a 
round ball, lying upon or in 
front of the body of the pubes 
to the outside of the femoral 
artery and vein. Larrey saw 
a patient in whom the femur 
w r as placed nearly at a right 
angle with the body; and Phys- 
ick once met with a dislocation 
upon the pubes "directly before 
the acetabulum," in which the 
limb was not at all shortened, but, on the contrary, a very little length- 
ened. 1 Other surgeons have occasionally seen similar examples. 

The differential diagnosis between a fracture of the neck of the femur 
and this dislocation may be thus briefly stated. In the fracture there 
is crepitus, mobility, slight eversion easily overcome, moderate or no 
shortening, no abduction, the trochanter major rotates on a short radius, 
and the head of the bone cannot be felt. In this dislocation there is no 




Dislocation upon the pubes below the anterior in 
ferior spine of the ilium. (From Bigelow.) 



1 Dorsey's Surgery, vol. i, p. 238, 1813. 



UPWARDS AXD FORWARDS UPON THE PUBES. 



717 



crepitus, the limb is immobile, the eversion is extreme and not easily 
overcome, there is generally more shortening, the thigh is abducted, 
the trochanter major rotates upon a longer radius, and the head of the 
bone can generally be distinctly felt in its unnatural position. 

Prognosis. — Sir Astley Cooper remarks that although this accident 
is easy of detection, he has known three instances in which it was 
overlooked, and he cannot but regard such errors as evidence of great 
carelessness on the part of the surgeon who is employed. 

The reduction has generally been accomplished, in recent cases; with 
no great difficulty ; and when not reduced, the patients have occasion- 
ally recovered with very useful 
limbs. 

Treatment. — From the several 
reported examples of dislocation 
upon the pubes reduced by ma- 
nipulation, it would be difficult 
to draw any practical conclusions, 
since the methods have differed 
so widely from each other. I 
shall mention only three, which 
may be found in our own jour- 
nals. One of these has already 
been mentioned in connection 
with the history of this process, 
as a case of compound disloca- 
tion, reduced by Dr. Ingalls, of 
Chelsea, Mass., and the two re- 
maining examples were both re- 
ported by E. J. Fountain, of 
Davenport, Iowa. Dr. Ingalls 
succeeded by carrying the limb 
into its greatest state of abduc- 
tion, and rotating the thigh in- 
wards; the replacement of the 
bone being aided also by pressing 
upon its head with his fingers 
thrust into the wound ; while 
Dr. Fountain succeeded equally 
in both of his cases, by an almost 
opposite mode of procedure, 
namely, by adducting the limb 
forcibly, rotating the thigh out- 
wards, and then flexing the thigh 
upon the body. The first of 
Dr. Fountain's cases occurred in 
June, 1854. The patient, an 
adult male, had fallen from the 
second story of a house to the 
ground, fracturing his lower jaw, and dislocating his left hip. The 
limb was a trifle shortened, and the foot strongly everted. The promi- 




Dislocation upwards and forwards upon the pubes. 



718 DISLOCATIONS OF THE THIGH. 

nence of the trochanter was lessened, and the head of the bone could 
be felt upon the pubes. Assisted by Dr. Arnold, he reduced the limb 
in the following manner : The patient was laid on the floor, and placed 
completely under the influence of chloroform. The dislocated limb 
was then " seized by the foot and knee and rotated outwards, the leg 
flexed and carried over the opposite knee and thigh, the heel kept well 
up, and the knee pressed down. This motion was continued by carry- 
ing the thigh over the sound one as high as the upper part of the 
middle third, the foot being kept firmly elevated. Then the limb was 
carried directly upwards by elevating the knee, while the foot was held 
firm and steady, at the same time making gentle oscillations by the 
knee, when the head of the bone suddenly dropped into its socket." 1 
The time occupied was not more than thirty seconds, and the force 
employed was very slight. 

The second case occurred on the 31st of October, 1855, in the person 
of John McCarthy, an Irish laborer; the dislocation having been 
occasioned by falling with a horse, while riding. The reduction was 
effected in about twenty seconds by the same process, and without the 
aid of chloroform. 

It is probable that no one method will succeed equally well in all 
cases ; but if the head of the bone, as in the case dissected by Sir 
Astley Cooper, has not only actually surmounted the pubes, but pushed 
itself fairly into the pelvis, then the limb ought to be abducted in the 
manner practiced by Ingalls, and forcibly rotated outwards, in order 
that the head may be thus lifted over the pubes ; and subsequently it 
should be flexed upon the body, adducted and brought down. But in 
this manoeuvre we ought to be careful not to continue the rotation out- 
wards after the head of the femur has risen above the pubes, lest the 
head and neck should grasp, as it were, the psoas magnus and iliacus 
internus muscles, underneath which they have been thrust. On the 
contrary, it will be necessary at this point to rotate the thigh again 
gently inwards, which, by compelling the head to hug the front of the 
pubes, will enable it, while the flexion is being made, to slide down- 
wards under these muscles toward the socket. If, however, the head 
of the bone has never risen upon the summit of the pubes, and is not 
actually engaged under the muscles which pass over it at this point, 
then the rotation outwards will not be necessary in any part of the 
procedure. 

Baron Larrey has reported a case of dislocation " before the hori- 
zontal portion of the pubes," which he reduced " by suddenly raising 
with his shoulder the lower extremity of the femur, while with both 
hands he depressed the head of the bone." 2 This is the same case of 
which we have already spoken as being attended with the unusual 
phenomenon of the thigh placed at a right angle with the body. 

If reduction is attempted, by extension, the patient ought to be laid 
on his back upon a table, with the dislocated limb falling off slightly 

1 Fountain, New York Journ. Med., Jan. 1856, p. 69 et seq. 

2 Larrey, Lond. Med.-Ohir. Rev., Dec. 1820, p. 500; vol. i, first series, from Bul- 
letin de la Fac. de M6d., No. 1. 



ANOMALOUS DISLOCATIONS. 719 

from its side. The extending band, made fast above the knee, should 
then be secured to a staple in the line of the axis of the dislocated 
thigh, and of course below the table ; while the counter-extending 
band, crossing under the perineum, should be made fast in the same 
line, above the level of the table, and beyond the head of the patient. 

When extension is commenced, and the head of the femur has begun 
to move, the reduction may sometimes be facilitated by lifting the 

Fig. 322. 



Reduction of dislocation upon the pubes, by extension. 

upper part of the thigh with a jack-towel or a band passed under the 
thigh and over the neck of the surgeon, as we have recommended in 
both of the backward dislocations. It may be found advantageous 
also to flex and rotate the limb after extension has brought the head 
near the socket. 



2 5. Anomalous Dislocations, or Dislocations which do not properly 

belong to either of the Four Principal Divisions 

before Described. 1 

1. Dislocations directly Upwards. 

Syn. — u Sous-cotyloidiennes ;" Malgaigne. " Sixth dislocation ;" Mutter. 

Malgaigne affirms that the head, in this dislocation, is situated ex- 
ternal to the anterior inferior spinous process, and about one inch below 

1 Malgaigne, Traite des Frac. et des Lux., torn, ii, p. 869 et seq. Samuel Cooper, 
First Lines, vol. ii, p. 391. Pirrie's Surg., Amer. ed., 1852, p. 275. Skey's Surg., 
Amer. ed., 1851, p. 110 et seq. Gibson's Surg., sixth American ed., vol. i, p. 386. 
Guy's Hospital Keports, vol. i, 1836, pp. 79 and 97; vol. iii, 1838, p. 163. London 
Lancet, Lond. ed., vol. i, 1848, p. 184 ; vol. ii, 1840, p. 281 ; vol. i, 1845, p. 412 ; 
vol. ii, p. 159. London Med. Gaz., vol. xix, pp. 657 and 659; vol. x, p. 19; vol. 
xxxiii, p. 404. Med.-Chir. Trans., vol. xx, p. 112. Lente's paper on " Anomalous 
Dislocations of the Hip-joint," in New York Journ. Med. for Nov. 1850, p. 314 et 
seq. Philadelphia Med. Examiner, No. 51. Amer. Journ. Med Sci., vol. xvi, p. 
14. New York Med. and Phys. Journ., 1826, vol. v, p. 597. New York Journ. 
Med., Jan. 1860, Dr. Shrady's case. Dislocation of the Hip, by Jacob J. Bigelow, 
M.D., 1869, p. 105. 



720 DISLOCATIONS OF THE THIGH. 

the anterior superior spinous process ("subspinous"). But this position 
is not uniform. It may be found in front of the inferior process, or 
above (" supraspinous") as well as behind, or external to it. 

The symptoms which characterize this accident are shortening of the 
limb, slight abduction and extension, with extreme eversion or rotation 
outwards. The eversion of the toes, together with the slight amount 
of shortening which has in general been observed, has led several times 
to the supposition that it w r as a fracture of the neck of the femur ; but 
the rigidity, and the position of the trochanter and head will usually 
render the diagnosis clear. 

The following is probably an example of the subspinous dislocation : 

Bennett Morris, set. 51, was thrown backwards, in wrestling, in 1851. 
He felt a snap in the hip-joint, and found his thigh placed in a posi- 
tion of moderate abduction, so that he could not get his knees together. 
He was able to walk, but not without limping. This condition con- 
tinued three years, during which time he was constantly lame, and 
suffered much pain when walking. 

At the end of this period, when in the act of jumping from his 
w r agon, his horses having become frightened, he felt a snap, and at 
once the complete functions of the joint were restored. He could walk 
without pain or halt, and he could bring his knees together. Three 
months later, while ascending a flight of steps, carrying a heavy 
weight, his foot slipped, and the luxation was reproduced, and in this 
condition it remained up to the period at which he consulted me, Oct. 
1869. I found the thigh apparently elongated, but upon measurement 
it was found shortened half an inch. It was moderately abducted and 
rotated outwards. All the motions of the joint were restricted. 

Although I felt very confident that the reduction could be again 
accomplished, the patient left without permitting me to make the 
attempt. 

Other surgeons have met with examples of the upward dislocation 
(subspinous) in which the patients have been able to walk quite well 
immediately after the accident. Bigelow supposes that in these cases 
the upper portion of the capsule has been completely torn from the 
margin of the acetabulum, and that the head has been permitted to 
ascend until it was arrested by the under surface of the ilio-femoral 
ligament at the point where it rises from the anterior inferior spinous 
process of the ilium. 

Cummins reports a case which occurred in the practice of Gibson, 
of New Lanark, where the head of the bone was believed to be situated 
just below the anterior superior spinous process, and inwards toward 
the pubes ("supraspinous"). The limb was shortened fully three 
inches ; the toes everted ; adduction and abduction were exceedingly 
painful and difficult, but flexion was more easily performed. The 
head of the bone could be felt in its new position, especially when the 
thigh was moved. At first it was supposed to be a fracture, but this 
error having been corrected, the surgeons proceeded to attempt reduc- 
tion on the eleventh day. Extension was made by pulleys, and when 
the head of the bone had descended to the margin of the cavity, Mr. 
Gibson lifted the upper end of the femur by means of a towel, at the 



ANOMALOUS DISLOCATIONS. 



721 



same moment pressing the knee toward the opposite thigh, and forcibly 
rotating the limb inwards ; by which means the reduction was accom- 
plished. 1 

Lente has seen the head of the femur in the same position as in the 
case reported by Cummins, not as a primitive dislocation, but conse- 
quent upon an attempt to reduce a dislocation into the ischiatic notch. 
The shortening was about two inches ; the limb very much rotated 
outwards ; the rotundity of the affected hip greater than that of the 



Fig. 323. 




Anterior oblique dislocation." (From Bigelow.) 



other, and the trochanter major one inch farther removed from the 
anterior superior spinous process. The head of the bone could be felt 
distinctly in its new position. 



Fig. 324. 




Mechanism of "anterior oblique dislocation." (From Bigelow.) 



The reduction was effected finally with pulleys, by the aid of chlo- 
roform, and by rotation of the limb in various directions. 2 

1 Cummins, G-uy's Hospital Keports, vol. iii, p. 163, 1838. 

2 Lente, New York Journ. of Med., Nov. 1850, p. 314. 



722 



DISLOCATIONS OF THE THIGH. 



Fig. 325. 



Morgan also reports a case in which the head of the femur was 
above the acetabulum, and a little to the outside of the ilio-pectineal 
eminence 1 (" subspinous "). 

In a majority of cases these dislocations have been reduced by ma- 
nipulation alone, or by manipulation aided by pressure. The limb 
should be seized in the usual manner, at the knee and ankle, carried 
up toward the face, abducted, then rotated inwards, gently adducted, 
and finally brought down again to the bed. At the moment when the 
rotation and adduction commence, the head of the bone should be 
pressed toward the socket by the hands, and, if necessary, lifted a little 
over the margin of the acetabulum, by moderate extension at a right 
angle with the body. 

Bigelow, who regards as irregular only those which are accompanied 
with a complete rupture of the ilio-femoral ligament, but whose classi- 
fication in that regard I am not fully prepared to adopt, has neverthe- 
less given us the most intel- 
ligible and most probable ex- 
planation of the mechanism of 
these irregular upwards dislo- 
cations, and of several other 
forms of irregular dislocations. 
According to this writer, the 
" anterior oblique dislocation," 
in which the limb is found 
greatly adducted, and at the 
same time strongly everted, is 
a regular dorsal dislocation, 
the head being advanced upon 
the dorsum to a point near the 
anterior margin of the ilium. 
If now the limb be brought 
down, the neck of the femur 
will be made to bear against 
the outer fibres of the ilio- 
femoral ligament, and as these 
gradually give way the head 
will become more and more 
hooked over the remaining 
fibres of the ligament, and above the inferior spinous process ("supra- 
spinous ") ; or, continued efforts being made to straighten the limb, the 
ligament will give way entirely, and the femur will assume the posi- 
tion indicated by the dotted lines. 

Bigelow recommends a plan of treatment essentially the same as that 
hitherto recommended by myself. "The anterior oblique dislocation 
may be reduced by inward circumduction of the extended limb across 
the symphysis, with a little eversion, if necessary, to disengage the head 
of the bone. Inward rotation then converts this into the common lux- 
ation upon the dorsum." In the supraspinous dislocation, he recom- 




Supraspinous dislocation. ( Bigelow.) 



Pirrie's Surgery, p. 276. See also Phil. Med. Exam., No. 51, Mutter's paper. 



ANOMALOUS DISLOCATIONS. 723 

mends also inward circumduction, with as much eversion as may be 
necessary to disengage the head from the pelvis, by which the disloca- 
tion is at once converted into dorsal. 

2. Dislocations Dowmvards and Backwards upon the Posterior Part of 

the Body of the Ischium, between its Tuberosity and its Spine. 

James C, set. 35, was admitted to the Pennsylvania Hospital, on the 
23d of January, 1835, under the care of Dr. Hewson. The patient, 
a muscular man, had been crushed under a falling roof, and, as he 
thought, with his right thigh separated from his body. When received 
into the hospital, one hour after the accident, the right thigh was flexed 
upon the pelvis, and rested upon the left; the right leg was also flexed 
upon the thigh ; the knee was below its fellow, the toes turned inwards, 
and the whole limb shortened at least one inch. The head of the bone 
could be felt distinctly resting upon that portion of the ischium which 
lies between the acetabulum, the tuberosity of the ischium, and the 
spine. 

On the following day, the muscles of the patient having been suffi- 
ciently relaxed by suitable means, the pulleys were applied; but, after 
a second attempt, some of the bands having given way suddenly, the 
pulleys were removed, when it was found that the reduction had been 
accomplished, although neither the patient nor his attendants had 
noticed the return of the bone to its socket. For several days there 
was entire loss of sensibility and motion in the leg, owing probably to 
the pressure which had been made upon the sciatic nerve ; but these 
symptoms gradually disappeared, and at the time when the case was 
reported, about two months after the accident, he was walking with 
crutches. 

Dr. Kirkbride, who has reported this unusual case of dislocation, 
doubts whether the extension was necessary to the reduction, as the 
head of the bone was brought very near the margin of the acetabulum 
by lifting the thigh with a towel, and it probably afterwards entered 
the socket so soon as the extension was relaxed. 1 

Malgaigne has referred to several similar examples. 

3. Dislocations Downwards and Backwards into the lesser or lower Ischi- 

atic Notch. 

Syn. — " Behind tuber ischii ;" Gibson, S. Cooper. u Fifth dislocation;" Gibson. 

September 7, 1821, Charles Lowell, of Lubec, Mass., was riding a 
spirited horse, when the animal, being restive, suddenly reared and fell 
back on his rider, in such a manner as that the weight of the horse 
was received on the inside of the left thigh; Mr. Lowell having fallen 
on his back, a little inclined to the left side. The surgeon, who was 
immediately called, recognized it as a dislocation, and thought he had 
succeeded in reducing it; but a day or two later it was seen by a second 

1 Kirkbride, Amer. Journ. of Med. Sci., vol. xvi, p. 13. 



724 DISLOCATIONS OF THE THIGH. 

surgeon, who declared that it was still out of place, and repeated the 
attempt at reduction, but without success, as the result proved. 

In December of the same year Mr. Lowell called upon John C. 
Warren, of Boston, who was now able to determine, easily, as he 
affirms, the precise character of the accident. The limb was elongated, 
contracted, and the head could be felt in its unnatural position. By 
advice of Dr. Warren, he was taken to the Massachusetts General 
Hospital, and a persevering attempt was there made to reduce the 
bone, but with no better success than had attended the efforts pre- 
viously made. 1 

Mr. Keate has reported a case produced in a very similar way by 
a horse having fallen backwards with the rider into a deep and narrow 
ditch ; but the position of the limb was somewhat extraordinary, con- 
sidering that it was a dislocation backwards, the whole limb being 
very much abducted and the toes being turned outwards, as if the 
head of the bone was in front of the tuber ischii, rather than behind it. 
The thigh and leg were much flexed, and the whole limb was short- 
ened from three to three and a half inches. The head of the femur 
could be distinctly felt " inferior to the ischiatic notch, and on a level 
with the tuberosity of the ischium." In the first attempt at reduction 
the head of the bone was thrown into the foramen ovale, from which 
it was, however, after one or two more attempts by extension, and by 
lifting with a jack-towel, restored to the socket. Mr. Keate believes 
that the dislocation was originally into the foramen ovale, but that in 
the struggles made by the patient to extricate himself, it was thrown 
backwards into the position in which he found it. 2 

Mr. Wormald has reported a primitive accident of the same kind, 
occasioned by jumping from a third-story window. The patient died 
soon after, and at the autopsy the head of the femur was found under 
the outer edge of the gluteus maxim us, projecting through the torn 
capsule opposite the upper part of the tuber ischii. The shaft of the 
femur lay across the pubes, and the limb was considerably shortened 
and turned inwards. 3 

4. Dislocations Directly Downwards, 

Syn. — " Sous-cotyloi'diennes ;" Malgaigne. 

The following is one of several similar examples now upon record: 
A man, set. 50, was admitted into the London Hospital under the 
care of Mr. Luke. A dislocation of the left femur was easily diagnos- 
ticated, but the symptoms were peculiar, inasmuch as the limb was 
lengthened one inch, without either inversion or eversion; yet the 
head of the bone could be easily felt, and was thought to be in the 
ischiatic notch. By manipular movements reduction was easily effected 

1 New York Med. and Phys. Journ., vol. v, p. 597, 1826. Letter to the Hon. 
Isaac Parker, etc., by John C. Warren, 1826. North Amer. Med. Journ., vol. iii, 
p. 169. 

2 Amer. Journ. Med. Sci., vol. xvi, p. 226, 1835; from Lond. Med. Gaz., vol. x, 
p. 19. 

3 Wormald, London Med. Gaz., 1836. ' 



ANOMALOUS DISLOCATIONS. 725 

about an hour after the accident. The man subsequently died from 
the effects of broken ribs. At the autopsy, Mr. Forbes, the house- 
surgeon, before dissecting the parts, again dislocated the bone. This 
was done with ease, and it was clear that the original form of disloca- 
tion had been reproduced, as the bone could not be made to assume 
any other position. The head of the bone proved to be displaced 
neither into the ischiatic notch nor the thyroid hole, but midway be- 
tween the two, immediately beneath the lower border of the acetab- 
ulum. The gemellus inferior and the quadratus femoris had been torn, 
the ligaraentum teres had been wholly detached, and there was a lacer- 
ation in the lower part of the capsular ligament. 1 

Dr. Blackman, of Cincinnati, informs me that, in January, 1859, he 
reduced a subcotyloid, incomplete dislocation, in a man set. 70, by 
manipulation, Dr. Judkins lifting the thigh upwards and outwards by 
means of a towel, while Dr. Blackman first flexed and then abducted 
the limb. 

5. Dislocations Forwards into the Perineum. 

Syn. — " Perineales ;" Malgaigne. "Luxation sur la branche ascendante de 
l'ischion;" D'Amblard. "Inwards on the ramus of the os pubis;" Skey. 

D'Amblard published an example of this accident in 1821, occa- 
sioned by a violent muscular exertion made by the patient in an effort 
to spring into his carriage, the symptoms attending which did not 
differ materially from those which were found to be present in the 
three following examples, except that in the first case the toes were 
turned slightly inwards, while in each of the other cases they were 
turned outwards. 2 

Mr. E., pet. 35, a calker by occupation. The injury was received 
while at work under the bottom of a canal-boat, July 20th, 1831, the 
boat being raised upon props three and a half feet long. The patient 
was standing very much bent forwards, with his feet far apart, be- 
tween which lay a piece of round timber one foot in diameter, when 
the props gave way, letting the whole weight of the boat upon him- 
self and his companions. One of the workmen was killed outright. 
On extricating Mr. E. from his situation, the left leg and thigh were 
found extended at a right angle with the body, the toes turned slightly 
inwards, the natural form of the nates was lost, and the head of the 
femur could be felt distinctly moving, when the limb was rotated, in 
the perineum, behind the scrotum, and near the bulb of the urethra. 

For the purpose of reduction, the patient was laid on his back upon 
a table, and the pelvis made fast by a muslin band. Extension, accom- 
panied with moderate rotation, was then made in a direction outwards 
and downwards, bringing the head of the bone over the ascending ramus 
of the ischium, beyond which it w 7 as lying, into the foramen thyroi- 
deum ; and from this position the bone was replaced in the acetabulum, 

1 Luke, Med. News and. Library, vol. xvi, p. 34, March, 1858 ; from Med. Times 
and Gaz., Jan. 2, 1858. 

2 Malgaigne, op. cit., torn, ii, p 876. 



726 DISLOCATIONS OF THE THIGH. 



rhe 



by carrying the dislocated limb forcibly across the opposite one. Th 
patient soon recovered the use of the joint. 1 

J. B., an Irishman, set. 40, on entering the St. Louis Hospital, gave 
the following account of his accident, which had occurred six hours 
previously. He was engaged in excavating earth, and having under- 
mined a bank, it unexpectedly fell upon his back while he was stand- 
ing in a bent position, with his thighs stretched widely apart. The 
weight crushed him to the earth, breaking both bones of his right leg, 
the radius of the same side, and dislocating the left hip into the peri- 
neum. The thigh presented a peculiar appearance, being placed quite 
at a right angle with the body, but somewhat inclined forwards. The 
part of the hip naturally occupied by the trochanter major presented 
a depression deep enough to receive the clenched fist ; while the head 
of the bone could be both seen and felt projecting beneath the skin of 
the raphe in the perineum. Rotation of the limb, which was difficult 
and excessively painful, rendered the position of the head still more 
manifest. The patient had also retention of urine, occasioned proba- 
bly by the pressure of the femur upon the urethra. Having dressed 
the fractures, Dr. Pope placed the patient under the full influence of 
chloroform, and then proceeded to reduce the dislocated thigh; for 
which purpose "two loops were applied, interlocking each other in 
the groin, and using the leg as a lever, extension, by means of the 
pulleys, was made transversely to the axis of the body. A steady 
force was kept up for a short time, and the thigh-bone glided into its 
socket with a snap that was heard by every attendant and patient in 
the large ward." 2 

A man, set. 22, was admitted to the Toronto Hospital, under the care 
of Dr. E. W. Hodder, January 15, 1855, having been injured by the 
fall of a bank of earth an hour before. The head of the right femur 
was found under the arch of the pubes, the neck resting upon the 
ascending ramus. The thigh formed nearly a right angle with the 
body ; it was also strongly abducted, and the toes were slightly everted. 
On the following day, the patient being placed under the influence of 
chloroform, extension and counter-extension were employed in the 
direction of the axis of the femur, that is, nearly at right angles with 
the body, while, at the same moment, the upper portion of the femur 
was lifted by a round towel. By this manoeuvre the head of the bone 
was carried into the foramen thyroideum. The force was now applied 
in a direction " more upwards and outwards ; the ankle held by the 
assistant was drawn under the other and at the same time rotated." 
In a few minutes the complete reduction was accomplished. His re- 
covery has been steady, and three weeks later he was discharged, being 
able to walk very well with the aid of a cane. 3 

1 W. Parker, New York Med. Gaz., 1841: N. Y. Journ. Med., March, 1852, 
p. 188. 

2 Pope. St. Louis Med. and Surg. Journ., July, 1850; IS". Y. Journ. Med., March, 
1852, p. 198. 

3 Hodder, British Araer. Journ., March, 1861. 



ANCIENT DISLOCATIONS OF THE FEMUR. 727 



I 6. Ancient Dislocations of the Femur. 

Says Sir Astley Cooper : " I am of opinion that three months after 
the accident for the shoulder, and eight weeks for the hip, may be 
fixed as the period at which it would be imprudent to attempt to make 
the reduction, except in persons of extremely relaxed fibre or of ad- 
vanced age. At the same time, I am fully aware that dislocations 
have been reduced at a more distant period than that which I have 
mentioned ; but in many instances the reduction has been attended 
with the evil results which I have just been deprecating." A remark 
which later surgeons do not seem always to have correctly understood, 
or which, if they have understood, they have not correctly represented; 
since it has many times been affirmed of this distinguished surgeon, 
that he regarded reduction of the hip as impossible after eight weeks, 
and they have proceeded to cite examples which would prove that he 
was in error. But long before Sir Astley's day, Gockelius mentioned 
a case of reduction of the femur after six months, and Guillaume de 
Salicet declared that he had reduced a similar dislocation after one 
year, 1 and Sir Astley says that he is "fully aware" of the existence of 
such facts j yet with a knowledge of what has so frequently followed 
these attempts, he would not recommend the trial after eight weeks, 
except under the circumstances by him stated ; and notwithstanding 
the number of these reported successes has been considerably increased 
in our day, we suspect that Sir Astley's rule will continue to govern 
experienced and discreet surgeons. Certain examples which have re- 
cently been published of successful reduction after six months by ma- 
nipulation, would encourage a hope that the period might be greatly 
extended, were it not that manipulation also has already failed many 
times in the case of ancient luxations, and that the attempt has some- 
times been followed with disastrous results, even in recent cases. 

The following are examples of reduction by manipulation after the 
lapse of six months : 

On the 21st of March, 1856, a man presented himself at the Com- 
mercial Hospital, Cincinnati, with a dislocation of the femur upon the 
dorsum ilii, of six months' standing. The limb was shortened two 
inches. Dr. Blackman, under whose care he was admitted, adminis- 
tered chloroform, and by manipulating after the method described by 
Dr. Reid, the reduction was accomplished. 2 

In a letter addressed to me by Dr. Blackman, and dated April 21st, 
1859, he informs me that this patient presented himself again before 
the class about six months since, and the restoration of the functions 
of the limb was found to be complete. 

The second example occurred in the practice of Martial Dupierris, 
of Havana, Cuba. A Chinese boy, named Ah-sin, aged about sixteen 
years, arrived at Havana on the 4th of June, 1856, suffering under a 
severe illness, which confined him for a month or more to his bed, 

1 Malgaigne, op. cit., torn, ii, p. 185; from Gallicinium Medico-practicum, Ulm, 
1700, p/288. 

2 Blackman, Ohio Med. and Surg. Journ., vol. viii, p. 522. 



728 DISLOCATIONS OF THE THIGH. 

and the existence of the dislocation was not discovered until he had 
sufficiently recovered to rise upon his feet. It was then ascertained 
that he had a dislocation of the left femur upon the dorsum ilii. Upon 
inquiry, Dr. Dupierris learned that the accident had occurred before 
leaving China, a period of more than six months. The boy was still 
feeble, the limb somewhat emaciated, and instead of being rigid from 
muscular contraction, all the muscles " were in a flaccid condition, 
except the great gluteal, which was painful to the touch." Deeming 
the use of anaesthetics improper, on account of the boy's feeble condi- 
tion, these agents were not employed. Dr. Dupierris describes the 
method of reduction as follows : " The body being held by two assist- 
ants by means of two bands, one of which passed beneath the peri- 
neum, and the other under the axilla?, traction was made upon the 
limb by two strong and intelligent assistants. The movement of the 
head of the bone, resulting from this manoeuvre, was very limited, 
even when the force w T as much increased; and the excruciating pain, 
which the patient referred to the iliac region, compelled us for the mo- 
ment to desist. 

" The following day, the patient having obtained a tolerable night's 
rest by means of a narcotic potion, I concluded to attempt the reduc- 
tion by flexion, believing that I could thus better prevent any accident 
which the necessary force might produce; the operator, in adopting 
this method, having it in his power to follow the head of the bone by 
pressure upon it with the hand, aiding its movement in the proper 
direction, or correcting any deviation that may occur. The emaciated 
condition of the boy was eminently favorable for such a procedure. 

"The patient being placed upon his back, and the trunk of the body 
made steady by assistants, with the left hand I grasped the upper part 
of the leg, placed the right hand upon the head of the bone in the 
iliac fossa, and then proceeded to flex the leg upon the thigh, and the 
thigh upon the pelvis. By this movement the great gluteal muscle 
was relaxed, and the head of the bone advanced, while with the right 
hand I directed the latter toward the cotyloid cavity. As soon as I 
judged the head to be immediately above the centre of the socket, I 
extended the leg, the thigh remaining flexed at a right angle; and 
then using the limb as a lever, I rotated it from within outwards, and 
at the same time extended it by making a movement of circumduction 
in a similar direction. When, by these procedures, the limb was brought 
near to its opposite fellow, a snap audible to the assistants, and of a 
deeper character than is ordinarily observed in the reduction of recent- 
dislocations, indicated the return of the head of the bone to its natural 
position ; a fact which was further substantiated by the establishment 
of the original length and form of the member and the subsidence of 
the pain. 

" The after-treatment consisted in placing a pad between the knees, 
and another between the internal malleoli, and confining the limbs 
together by two bands, one above the knees, and the other around the 
lower part of the legs. But in spite of these precautions to prevent 
redisplacement, the next morning I found that the dislocation had 
been reproduced. It was again reduced, but for three successive days 



ANCIENT DISLOCATIONS OF THE FEMUK. 



729 



there was a redisplacement. After this, however, the head of the bone 
kept its place; passive motion was daily employed, and all suffering 
ceased. After twenty days of rest, and a liberal use of the lactate of 
iron, the patient was allowed to get up; and, being provided with a 
pair of crutches, upon which he exercised himself daily, improved 
very rapidly. The muscles gradually recovered their bulk and vigor, 
and at the end of forty-eight days he was enabled to walk without 
crutches, although with some fear of falling. About the middle of 
August he was put to work in a cigar manufactory, and has continued 
well ever since." 

The third is a case reported by Dr. A. "W. Smyth, of New Orleans. 
The dislocation was upon the dorsum ilii, of nearly nine months' 
standing; and it was reduced by manipulation, in the first attempt. 
The reduction was accompanied with " a good deal of snapping and 
breaking." 

Dr. Brown, of Boston, has published an interesting case of reduction 
of an ancient dislocation of the hip in a child 8 years old. He believes 
the dislocation to have been caused by rheumatic arthritis. In the 
same connection he has furnished a table of the cases of reduction of 
ancient dislocations of the hip, which he has found upon record. 1 I 
republish the table, with a single correction, and one addition. 



Surgeon. 








Time. 


Gockelius, .... 180 days. . 


Salicet, . . 


. . . 365 « 


Dupuytren, 






31 " 


Dupuytren, . 






. 78 " 


Dupuytren, . 






99 " 


Dupierris, . 






180 " 


Breschet, 






72 « 


Cooper, . . 






. 26 « 


Cooper, . . 






5 years. . 


Liston, . . 






35 days. . 


2 years. . 


Guillaume de Salicet, 365 days. . 


Hayward, 


Crosby, . 








68 « 


Atlee, 








. 120 " 


"Williams, 








. 150 " 


Bigelow, 








90 " 


Bigelow, 








240 " 


Bigelow, 








28 " 


Blackman, 








180 " 


Smyth, . 








270 " 


Brown, . 








. 105 " 


Kimball, 








90 » 


Moliere, . 








50 " 



Authority. 

. Gallicinium Med.-practicum, p 288. 

. Ibid. 

. Op., chap. 19. 

. Ibid. 

. Ibid. 

. Hamilton, Frac. and Dis., p. 679. 

. Kepertoire Generale. 

. Dislocations and Fractures, p. 35. 

. Ibid., p. 81. 

. Ibid., p. 45. 

. Mem. de l'Acad. Koy. de Chir. de Paris, 

torn, v, p. 529. 

. Malgaigne, torn, ii, p. 281. 

. Op.,' p. 71. 

. Trans. Am. Med. Assoc, vol. iii, p. 356. 

. Ibid., p. 357. 

. Lancet, 1862, vol. i, p. 665. 

. Dis. and Fract. of Hip, p. 211. 

. Ibid., p. 55. 

. Ibid., p. 54. 

Ohio Med. and Surg. Jour. , vol. viii, p. 522. 

. New Orleans Jour. Med., Jan. 1, 1869. 

. Northwestern Med. and Surg. Journal, 

June, 1870. 
. Lyon Jour. Medicale, No. 4 ; also Month. 

Ab. Med. Sci., vol. i, p. 269, 1874. 



In the comparison of the relative value and hazards of the different 
modes of reduction, I have cited several examples of fracture of the 



1 Spontaneous dislocation on dorsum ilii. Keduction after several months. 
Francis Brown, M.D., Surgeon to the Children's Hospital, etc., etc., Boston.. 

47 



By 



730 DISLOCATIONS OF THE THIGH. 

neck of the femur in the attempt to reduce old dislocations. In some 
cases the results have been much more serious. 

A man, 29 years old, was received at La Pitie, Paris, on the 13th of 
May, 1868, with dislocation of the hip of seven months' standing. 
M. Broca attempted to reduce it, using a force of 480 lbs. No reduc- 
tion was obtained, and the patient insisted upon leaving the hospital 
five days afterward. A fortnight then elapsed, when he presented 
himself at another hospital, with the hip enormously swollen, and died 
the next day of peritonitis. The autopsy showed that the head of the 
bone lay in the ischiatic notch, that it was held firmly by bundles of 
the torn capsule, and that the cotyloid cavity was much shrunk. Pus 
was found in the capsule, in the iliac fossa, in the articular cavities, 
and had found its way into the peritoneum, through the obturator 
foramen. 1 

The following case seems deserving of mention, for the reason that 
it is the first, so far as I am aware, in which an attempt has been made 
to reduce the dislocation after a subcutaneous division of the capsule : 

Thomas Jordan, set. 28, of Utica, N. Y., was sent to me by my 
former pupil, Dr. Jenkins, in January, 1869, having a dislocation of 
his left femur upwards and backwards upon the dorsum ilii. His 
account of the case was, that seven months before he was thrown in 
wrestling; a surgeon was called on the following day, and finding a 
dislocation, he placed him under the influence of an anaesthetic, and, 
as he supposed, reduced the dislocation by manipulation. 

The case did not come under the notice of Dr. Jenkins until a few 
weeks before he was sent to me, and although the character of the 
accident was recognized, no attempts were made at reduction. 

I found the limb rotated inwards, adducted, and shortened two inches. 
Before the class of medical students at Bellevue, assisted by Drs. Sayre, 
Crosby, Howard, and others, I made an attempt, January 29th, to break 
up the adhesions and reduce the dislocation, the patient being fully 
under the influence of ether. We were able to move the limb quite 
freely in various directions ; but after a trial of nearly an hour, we 
abandoned the attempt, having failed to accomplish reduction. 

A few days later I applied extension, by means of adhesive plaster 
and a cord, with a weight of twenty pounds. This was continued un- 
remittingly until February the 24th, when he was again placed under 
the influence of ether before the class. Assisted by Drs. Stephen Smith, 
Howard, Cross, and others, attempts were made to reduce the bone by 
manipulation, but without success. Believing now that the untorn 
portion of the capsule, and particularly the ilio-femoral ligament, con- 
stituted the chief obstacle to the reduction, I introduced a long, firm, 
but narrow bistoury, w r hich I had had made for the purpose, just above 
the trochanter major, carrying its point inward until it touched the 
neck at the base of the trochanter. From this point, the edge of the 
knife being directed towards the head of the bone, I swept the point of 
the knife slowly along until the head was distinctly felt, the point 
touching the neck apparently in its whole length. This was accom- 

i New York Med. Kecord, Dec. 16, 1868. 



PARTIAL DISLOCATIONS OF THE FEMUR. 731 

plished without enlarging the external opening. While the incision 
was being made the limb was kept rotated outwards, and abd acted as 
much as was possible, and it was felt to yield distinctly, so that both 
rotation outwards and abduction were more complete afterwards than 
before. I then divided also the tensor vaginse femoris ; and now the 
attempts at reduction were repeated, both by manipulation and exten- 
sion, but without success. 

The result of this attempt to reduce the dislocation by division of 
the ilio-femoral ligament, although unsuccessful, encourages a hope 
that it may sometimes succeed ; and I shall not hesitate to repeat the 
experiment, if a favorable opportunity is presented. 

I 7. Partial Dislocations of the Femur. 

Malgaigne declares that certain experiments made upon the cadaver 
led him, at one time, to the conclusion that all primitive luxations of 
the femur were incomplete, and that the old complete luxations found 
in autopsies had become so consecutively. Later observations have 
taught him to correct this error, yet he still finds " incomplete back- 
ward luxations quite common, and incomplete dislocations in all the 
other directions much more common." 

I have more than once found occasion to call in question the accu- 
racy of Malgaigne's views in relation to partial dislocations, the rela- 
tive frequency of which he seems constantly disposed to greatly exag- 
gerate. We cannot see the propriety of calling those cases partial 
dislocations, in which the head of the bone has fairly left the cotyloid 
cavity, and mounted upon its margin, even if it remains in this position 
without tearing the capsule ; since the articular surfaces are now as 
completely separated as if the capsule had given way, and the head of 
the bone had escaped through the laceration. It is in fact a complete 
luxation. But I doubt very much whether the head of the bone ever 
rests upon the margin of the acetabulum without tearing the capsule, 
unless it has previously undergone certain pathological changes, such 
as I have already described ; at least I cannot hesitate to reject all 
those examples in which the head of the femur is supposed to rest upon 
the upper or outer margin of the acetabulum ; and if I permit myself 
to speak of incomplete dislocations at all in this connection, I shall 
reserve the term for those rare cases in which the head of the femur 
becomes engaged in the cotyloid notch, after breaking down the fibrous 
band which, in the natural state, is continuous with the rim of the 
acetabulum. 

Of this form of dislocation, I think I have met with two examples ; 
one of which was in the person of the boy Lower, already mentioned, 
whose thigh was reduced accidentally by his father; and the other 
occurred in a boy fifteen years of age, residing at that time in Rutland, 
Vermont. He was brought to me on the 28th of May, 1842, by Dr. 
Haynes, of Rutland, at which time the dislocation had existed five 
years. His account of himself was that in walking upon a slippery 
floor, his left leg slid outwards and backwards in such a manner as 
that when he fell it was fairly doubled under his back. On the tenth 



732 DISLOCATIONS OF THE THIGH. 

day following the accident he began to walk with some help, and he 
has continued to w T alk ever since, but with a manifest halt. Three 
months after the injury was received, it was first seen by several 
surgeons, who pronounced it a dislocation, and attempted reduction 
without mechanical aid, but were unsuccessful. 

When the young man was brought to me, the limb was neither 
lengthened nor shortened, but the thigh was forcibly abducted and 
rotated outwards. It could not be flexed nor greatly extended. The 
head of the femur could be distinctly felt, as it lay anterior to the 
socket, but not sufficiently far forwards to rest upon the foramen ovale. 

J. C. Warren, of Boston, has reported a similar example in a child 
six years old, who was brought, April 21, 1841, to the Massachusetts 
General Hospital. Dr. Hale, who saw the lad at the end of two weeks, 
thought it a dislocation, but it had been treated by another surgeon 
as a case of hip-disease. The dislocation had now existed eight or 
ten weeks. The limb was a little lengthened, abducted, turned out- 
wards, and advanced in front of the body, with very slight motion of 
either flexion or extension, and almost no tenderness about the joint. 
Dr. Warren, also, was able to feel indistinctly the head of the bone 
" immediately external to, and in contact with, the insertion of the 
triceps and gracilis muscles." 

An attempt was made by manual extension and manipulation to 
accomplish the reduction, but without success. 1 

It is probable that both the above cases, which I have described at 
length, were examples of partial dislocation; yet I cannot conceal 
from others a doubt which I actually entertain whether they were not, 
after all, only examples of hip-joint disease, arrested after having 
wrought certain slight pathological changes in the joint and the tissues 
adjacent. If, however, they were not examples of incomplete disloca- 
tions of the hip-joint, then I question whether any such cases have 
ever occurred. 

I 8. Coxo-Femoral Dislocations, complicated with Fracture of 

the Femur. 

Such complications are exceedingly rare, but it will not do to deny 
their possibility ; although in some of the cases reported, the testimony 
is so incomplete as to leave a doubt whether the surgeons have not 
erred in their diagnosis. 

James Douglas has reported a case of dislocation upon the pubes, 
complicated with a fracture of the neck of the femur, the actual con- 
dition of which was verified by an autopsy ; the patient having died 
twelve years after the injury was received. The head of the femur 
still remained above the pubes, and was in no way connected with its 
neck or shaft. The upper end of the femur projected in the groin, 
lying upon the inside of the femoral artery and vein. Many other 
curious pathological changes had also occurred. 2 

1 Warren, Bost. Med. and Surg. Journ., vol. xxiv, p. 220. 

2 Amer. Journ. Med. Sci., vol. xxxiii, p. 455, from Lond. and Edin. Month. Journ. 
of Med. Sci., Dec. 1843. 



COXO-FEMOEAL DISLOCATIONS WITH FRACTURE. 733 

The well-authenticated examples of reduction of the dislocation, 
where the femur was broken also, are still more rare ; and several of 
the recorded examples which my researches have discovered, need 
additional confirmation. 

John Bloxham, of Newport, in the Isle of Wight, claims to have 
reduced a dislocation of the femur on the pubes, which was accom- 
panied with a fracture of the thigh a little above its middle. The 
following is the account of this interesting case which we find in the 
London Medico- Chirurgical Review, copied from the Medical Gazette of 
August 24th, 1833. We regret that we are unable to see the account 
as published in the Gazette, which might supply some circumstances 
important to a full appreciation of the case : 

On the seventh or eighth day after the accident, " the patient was 
laid on his back upon the bed, and kept in that position by means of 
a sheet passed across the pelvis and fastened to the bedstead ; another 
sheet was also passed over the left groin, and secured in a similar 
manner. The dislocated and fractured limb was then inclosed in 
splints, one of which extended up the back of the thigh as far as the 
tuberosity of the ischium. Pulleys, which were secured to a staple in 
the ceiling, placed at the distance of a foot to the right of a point ver- 
tical to the patient's navel, were then attached to a bandage fastened 
round the splints as high up as possible. 

" The foot was raised with the knee extended, so as to bring the 
limb nearly to a right angle with the line of the tackle, when, by 
drawing gradually on the cord, in the course of about ten or fifteen 
minutes the head of the bone was rendered movable, and was brought 
considerably more forward. I then began to press on the head of the 
bone, so as to push it downwards, whilst the pulleys held it partially 
disengaged from the pelvis. In a few minutes the head of the bone 
passed over the ridge of the os pubis, and I then directed the foot to 
be raised a little higher, which, by putting the gluteii muscles more 
upon the stretch, was calculated to render them more efficient in draw- 
ing the bone into its proper place. By this manoeuvre, the head of 
the bone was drawn backwards, and on the foot being more elevated 
and the cord slackened, it continued to recede from my fingers till the 
trochanter major made its appearance in the natural situation, and the 
reduction was found to be perfectly complete. 

" Lest the head of the bone should slip backwards on the dorsum 
ilii, I directed an assistant to apply firm pressure during the latter part 
of the process, above and behind the acetabulum. 

" The apparatus was then removed, the thigh bound up in short 
splints, and the patient laid upon a double-inclined plane. No symp- 
toms of inflammation appeared afterwards about the joint. Passive 
motion was employed at the end of a week, and occasionally repeated 
during the whole reparatory process." 1 

Without intending to question the accuracy of the statements in this 
case, which, in the main, seem to bear the marks of credibility, we 
must express our surprise that so little difficulty was experienced in 

1 Lond. Med.-Chir. Kev., vol. xix, p. 420, Oct, 1833. 



734 DISLOCATIONS OF THE THIGH. 






the reduction' if the femur was actually broken, no more, indeed, than 
is usually experienced when the bone is not broken ; and that Mr. 
Bloxham was able to employ safely passive motion at the end of a 
week. 

Charles Thornhill relates, in the London Medical Gazette for July, 
1836, a case of fracture of the femur through its upper third, in a 
man, set. 40, with dislocation into the ischiatic notch; which disloca- 
tion, he assures us, was reduced at the end of six weeks. But it is 
much more probable that, instead of reducing a dislocation, he refrac- 
tured the bone. During more than one hour and a half, aided by 
pulleys, tractions and manipulations were made in almost every direc- 
tion. 

The upper part of the thigh was lifted with all the strength of one 
man by means of a jack-towel; it was violently rotated, adducted, and 
abducted. Both the perineal and the knee band gave way, from the 
excess of the force employed ; and, finally, the head of the femur 
resumed its place with an audible crash. After which the " limb was 
of nearly equal length with the other ;" but there remained an " im- 
mense deposit" around the acetabulum. 1 

Malgaigne says that M. Eteve found a poor fellow with a disloca- 
tion of his left thigh backwards, a fracture near its middle, a penetrat- 
ing wound of the knee, and a fracture of the fibula in the same leg. 
Without delay he proceeded to reduce the dislocation by directing two 
assistants to support the body, three to support the leg, and two more 
to make extension from a towel tied not very tightly around the thigh 
above the fracture. The leg was then extended upon the thigh, and 
the thigh flexed upon the pelvis until it was at a right angle with the 
body ; and after a gradual extension had been made in this direction, 
M. EteVe pushed with all his strength the head of the bone into its 
socket. Of which case Malgaigne justly remarks, that the " extension" 
practiced by the surgeon was only imaginary. 2 If the reduction was 
accomplished at all, it was by manipulation and pressure. 

Finally, Markoe relates, in the paper to which we have already 
several times made allusion, the case of a boy set. 8, who was admitted 
into the New York City Hospital y on the 29th of June, 1853, with a 
compound fracture of the right thigh, a simple fracture of the left, and 
a dislocation of the head of the right femur upwards and backwards 
upon the dorsum- ilii. 

When placed upon the bed, the right limb lay obliquely across the 
abdomen of the boy, with the foot resting against the axilla of the 
left side. "The house-surgeon, to whose care the case fell on admis- 
sion, took the injured limb in his hands and very carefully carried it 
over the abdomen to the right side, and then adducted it and brought 
it down toward the straight position," during which procedure the 
head of the bone is supposed to have resumed its place in the socket. 3 

Such is the account furnished of the symptoms and treatment of 

1 Amer. Journ. Med. Sci., vol. xxv, p. 218. 

2 Malgaigne, op. cit., torn, ii, p. 206 ; from Gazette Med., 1838, p. 757. 

3 New York Journ. Med., Jan. 1855, p. 30. 



VOLUNTARY DISLOCATIONS OF THE FEMUR. 735 

this extraordinary case; too meagre, certainly, to entitle it to much con- 
fidence, or to permit us to draw from it any practical inferences. We 
are not even informed what was the name of the young man who alone 
saw and treated the case, nor what was his responsibility as a surgeon. 

I have been unable to find any other examples of fracture of the 
femur complicated with dislocation ; and, rejecting at least Mr. Thorn- 
hill's case as altogether incredible, the proper conclusion would be,, 
that reduction is sometimes possible in recent cases, if the surgeon will 
resort promptly, before swelling and muscular contractions have taken 
place, to manipulation combined with pressure upon the head of the 
bone. Indeed, it is probable that pressure alone is the means upon 
which the success will finally depend. Kichet says that he has several 
times dislocated the femur in the cadaver ; and then, having sawn off 
the head so as to represent a fracture, he has always been able to push 
the head of the bone easily into its socket. 1 By seizing the moment 
then when the patient is laboring under the shock, or by placing him 
completely under the influence of an anaesthetic, no resistance will be 
offered by the muscles any more than in the cadaver, and the reduction 
may, perhaps, be easily effected. 

I have no confidence that anything can be accomplished by exten- 
sion ; nor do I think it will be best to wait until the femur has united, 
since such delay will probably render the reduction impossible. 

§ 9. Voluntary Dislocations of the Femur. 

Examples in which persons, having suffered no disease of the hip- 
joint, have been able voluntarily to dislocate the femur, have, from 
time to time, been recorded, but I am not aware that any dissections 
have ever been made in these cases. I shall, therefore, not attempt 
any explanation of the facts, but simply record them as matters of 
curious interest, and for the purpose of inducing others to make of 
them a subject of investigation. 

Sir Astley Cooper mentions the case of a man who could throw out 
the head of the thigh-bone at pleasure, and reduce it with equal 
facility. A similar case is alluded to by Samuel Cooper, in his First 
Lines. Gibson mentions a case reported by Dr. Lewis, of North Caro- 
lina. 2 Dr. Bigelow has seen two cases, both of which were dorsal. 
Dr. Moore, of Rochester, has furnished an account of the case of John 
Parker, whose leg was first partially dislocated at Drury's Bluff, May 
13, 1864, and which was at the time reduced by his companions. The 
accompanying illustrations (Figs. 326, 327, p. 736) were obtained from 
photographs, and indicate the position of his limb when a voluntary 
subluxation upon the dorsum existed. 

The following case was reported to me in 1865, by John M. Forrest, 
M.D., of Portland, Maine, to whom the man presented himself as a 
"substitute," while Dr. Forrest was in the service of the U. S. Army. 
The application was rejected. 

" William G. Gliddon, set. 37, farmer, says that he has been able to 

1 New York Journ. Med., March, 1854, p. 293; from Bullet, de Ther. 

2 Gibson's Surgery, vol. i, p. 367, 6th ed. 



736 



DISLOCATIONS OF THE THIGH. 



dislocate and replace the femur at the left hip-joint since he was a boy. 
It is not the result of any injury or disease, so far as he knows. He 
is in good health, and his muscular development is complete. He 
accomplishes the dislocation by throwing the weight of his body upon 



Fig. 326. 



Fig. 327. 





Voluntary subluxation upon the dorsum ilii. (From Bigelow.) 






the left leg, and then contracting certain muscles about the hip. The 
reduction is generally more difficult than the dislocation, sometimes 
requiring the aid of his hand. When the head of the bone is out, 
there is a marked projection above and behind the trochanter major, 
apparently caused by the pressure of the head in this situation ; the 
limb is very slightly if at all everted ; while out of place it causes 
pain ; and after a few repetitions the pain becomes so great as to com- 
pel him to desist. The limb was not measured while it was dislocated. 
When the limb is in position he does not walk lame." 

The following is the only case which has come under my personal 
observation : Dr. William G. S., set. 24, received an injury on the out- 
side of the right knee, in February, 1862, from the kick of a horse. 
There was no apparent injury of the hip. On the fourteenth day after 
the accident he rode forty miles on horseback, which was followed by 
some stiffness in the right hip. Two weeks later, in mounting his 
horse, he felt something slip in the hip-joint. From that day until 
this, a period of four years, he has been able to reproduce the same 
slipping voluntarily, and which phenomenon I recognize as a disloca- 
tion upwards and backwards. I have examined him more than once, 
and he has dislocated and reduced the dislocation in my presence re- 



DISLOCATIONS OF THE PATELLA OUTWARDS. 737 

peatedly. Planting his right foot firmly upon the floor a little in ad- 
vance of the left, with his toes turned out, he throws his weight upon 
the right leg by carrying his pelvis well over to the right, and then 
contracts powerfully the gluteal muscles. Instantly the head leaves 
the socket, and seems to mount upon the dorsum; the trochanter major 
becomes rotated inwards, causing a slight inward rotation of the leg 
and foot. He can do the same when lying on his back, but not with 
the same ease. Reduction is accomplished without change of position, 
but by what precise manoeuvre I have not determined. The reduction 
is more quiet, and less sudden, apparently, than the dislocation. Both 
manoeuvres are accompanied with some pain. He is not lame, nor 
does the dislocation take place without his volition. I have seen one 
case, also, which, although pathological in character, was nevertheless 
caused by an early injury, and as such may properly be noticed in this 
connection. 

Dr. O. Gillett, set. 65 (1867), of Western ville, Oneida Co., 1ST. Y., was 
injured in his left hip-joint when 16 years old, by lifting a heavy 
weight. He felt at the moment something give way in the joint, and 
he has been lame ever since ; at first he was quite lame, but after a 
time the soreness about the joint diminished, and up to within about 
three years the lameness was chiefly due to a lack of development in 
the limb. Since then the joint has again become tender, and during 
the last nine months he has been able to throw the head of the bone 
out of the socket, backwards and upwards. Indeed, the bone is dislo- 
cated whenever he sits down, and resumes its place again when he 
stands up. It is quite apparent that the upper and outer margin of 
the acetabulum is partly absorbed ; and probably, also, the head and 
neck of the femur are in some measure deformed and absorbed. The 
dislocation is apparently incomplete ; and while it exists the thigh is 
abducted and slightly rotated outwards. This abduction arid outward 
rotation does not properly belong to a dislocation upon the dorsum of 
the ilium; but as the condition of the joint and of the adjacent muscles 
is abnormal, it will not require to be explained. 



CHAPTER XVII. 

DISLOCATIONS OF THE PATELLA. 

I 1. Dislocations of the Patella Outwards. 

Causes. — In the majority of cases it has been occasioned by muscular 
action ; and especially is this liable to occur in persons who are knock- 
kneed, or whose external condyles have not the usual prominence an- 
teriorly. It may be caused by suddenly twisting the thigh inwards 
while the weight of the body rests upon the foot, and the leg is thus 
kept turned outwards ; or by falling with the knee turned inwards 
and the foot outwards. Occasionally it is the result of a blow received 
upon the inside, or upon the front and inner margin of the patella. In 



738 



DISLOCATIONS OF THE PATELLA. 



some persons there seems to exist a preternatural laxity of the liga- 
mentum patellae or of the tendon of the quadriceps extensor, which 
exposes the subject to this accident from very trifling causes. Fergus- 
son says he has known it to be occasioned by a child's stepping upon 
the knee of a person lying in bed ; and Skey says he has seen two cases 
which occurred spontaneously during sleep. B. Cooper has seen a 
young lady who frequently dislocated her patella outwards by merely 
striking her toe against the carpet, or in dancing. Boyer, Sir Astley 
Cooper, and others mention similar examples. 

Pathological Anatomy. — Most frequently the dislocation is only par- 
tial, the inner half of the patella resting upon the articular surface of 
the outer condyle; and in consequence of the peculiar obliquity of these 
surfaces, together with the action of the vasti and rectus femoris, the 
outer margin of the patella becomes tilted forwards. 

If the dislocation is more complete, this margin begins to fall over 
backwards, as in the accompanying drawing; and in more extreme 
cases the patella lies flat upon the outer side of the condyle, with its 
inner margin directed forwards. 

When the dislocation is partial, it is probable that neither the cap- 
sule nor the ligamentum patellae usually suffers much laceration ; but 
in complete dislocations the capsule at least must 
have given way more or less. Norris, of Philadel- 
phia, reports a case of partial luxation in which the 
complications were more serious. John Scanlin, set. 
32, was admitted to the Pennsylvania Hospital, on 
the 27th of August, 1839, in consequence of injuries 
received a short time previous by having become en- 
tangled in machinery. In addition to several frac- 
tures in other limbs, he was found to have a subluxa- 
tion of his left patella outwards, its outer edge being 
much raised, and resting on the side of the external 
condyle of the femur, while its inner edge was de- 
pressed, and firmly fixed in the hollow between the 
condyles. The internal lateral ligament of the knee 
was ruptured, allowing the head of the tibia to be 
moved considerably outwards. A depression existed, 
also, between the tubercle of the tibia and the lower 
end of the patella, at the middle and inner side of 
the knee, evidently produced by a rupture of the liga- 
mentum patellae in nearly its whole extent. There 
was almost no swelling, and the limb was moderately flexed. By firm 
pressure the patella could be restored to position, but as soon as the 
hand was removed it returned to its original position. At the end of 
two months "a good degree of motion existed at the knee-joint, which 
was in no way inflamed or painful." 1 

Symptoms. — The limb is slightly bent, but immovable; the breadth 
of the knee is considerable increased; the inner condyle projects un- 
naturally, and the patella is distinctly felt upon the outer side. If the 




Dislocation of the pa- 
tella outwards. 



1 Norris, Amer. Journ. Med. Sci., vol. xxv, Feb. 1840, p. 276. 



DISLOCATIONS OF THE PATELLA OUTWARDS. 739 

dislocation is partial, the outer margin of the patella forms an irregular 
sharp ridge in front of the external condyle. If it is complete, the 
inner margin presents itself in front of the external condyle, and the 
outer margin looks backwards. Usually the patient suffers great pain 
asjong as the dislocation remains unreduced. 

Watson, of New York, saw a case of complete dislocation of the 
patella outwards in a fat young lady with lax fibre, and occasioned by 
dancing. He says the knee was slightly but firmly flexed. It was 
reduced by a very slight pressure with the fingers, and although some 
inflammation with effusion into the joint ensued, the use of the limb 
was completely restored in a week or ten days. 1 

Prognosis. — Reduction is in general easily accomplished, but a re- 
luxation is very prone to occur. In the few examples reported of a 
permanent luxation, the patients have eventually recovered the use of 
the limb in a great measure- Boyer saw four cases of this kind, in 
three of which it existed in the left leg, and had remained from infancy. 
The patella? were easily replaced, but unless confined they soon became 
displaced again; not one of them found it necessary to apply for surgi- 
cal aid, as " they suffered no great inconvenience from the luxation, 
and it exempted them from military service." 

After reduction, very little or no inflammation usually follows. Mr. 
Key has, however, narrated a case in Guy's Hospital Reports, of death 
from suppuration in the knee-joint, following upon the reduction of an 
inward subluxation. The dislocation was produced by a fall while 
carrying a pail, and was reduced by very gentle pressure ; but the 
patient, a girl set. 20, although apparently in good health, was believed 
to be somewhat strumous. 2 

Treatment — In order to relax completely the quadriceps extensor, by 
whose action chiefly the patella is held in its unnatural position, the 
body should be bent forwards, while at the same moment the leg is 
extended upon the thigh and the thigh flexed upon the body. The 
surgeon will accomplish these indications in the most simple manner 
by placing the patient in a chair and then lifting the foot upon his own 
shoulder, as he kneels or sits before him. Sometimes the patella will 
resume its position at once when this manoeuvre is adopted; but if it 
does not, slight lateral pressure, made with the fingers, will generally 
be found sufficient to accomplish the reduction. 

A man, set. 27, was sitting on a box, and in jumping off tripped 
himself with his right leg, causing a partial dislocation of the patella 
of the left leg outwards. Half an hour after the receipt of the injury 
I found him sitting with the knee bent, and in great pain. The patella 
lay upon the outer half of the articular surface, with its outer margin a 
little tilted upwards. Lifting the leg and thigh to a right angle with the 
body, and making very slight pressure upon the outer margin of the pa- 
tella, it immediately resumed its place. Very little inflammation ensued. 

In some instances, where other means have failed, the reduction 
has been effected by violent flexion and extension of the knee, aided 
by lateral pressure. 

1 Watson, New York Journ. Med., vol. i, p. 306. 2 Op. cit., vol. i, p. 260. 



740 



DISLOCATIONS OF THE PATELLA. 



I have already mentioned, when speaking of dislocations into the 
foramen thyroideum, the case of N. Smith, in whose person I found at 
the same moment a dislocation of the thigh, a subluxation outwards 
of the tibia, and a complete outward luxation of the corresponding 
patella. This was occasioned by a fall from a height upon the inside of 
the knee. I reduced the tibia first, and then easily replaced the patella 
by lifting the leg and pushing with my fingers against its outer margin. 

In many cases the patients themselves have reduced the dislocation 
immediately, and the surgeon is only consulted in relation to the after- 
treatment. Liston says that this is so constantly the fact, or else such 
dislocations are really so rare, that it has never happened to him to 
have an opportunity of reducing any form of dislocation of the patella. 

A young gentleman, set. 25, residing in Somerset, N. Y., called upon 
me in consequence of having discovered a floating cartilage in his knee- 
joint. His account of the matter was that on the 1st of February, 
1858, he was kicked by a cow upon the outside of the right leg, about 
six inches below the knee, and that he~immediately found the patella 
dislocated outwards. After several efforts, he finally succeeded in re- 
ducing it himself. His knee soon became greatly swollen, so that for 
five weeks he was unable to walk, and he has been more or less lame 
to this time. Six months after the accident he discovered a floating 
cartilage on the inside of the patella, about one inch in diameter, which 
occasionally slips between the joint surfaces, and suddenly trips him up. 

I 2. Dislocations of the Patella Inwards. 

Causes. — Less frequent than dislocations outwards, they are occa- 
sioned generally by direct blows received upon the outer margin of the 
patella. 

The symptoms, pathological anatomy, and treatment, will be the 
same as in dislocations outwards, except so far as 
these must necessarily vary from the opposite posi- 
tion of the patella. 



Fig. 329. 




§ 3. Dislocations of the Patella upon its Axis. 

Syn. — "Semi-rotation;" Miller. " Luxation Verticale ;" 
Malgaigne. 

These accidents, of which I have found recorded 
about twenty examples, and one additional case has 
been seen by myself, seem to be the result of the 
same causes which produce lateral luxations; and, 
indeed, they may be regarded as only exaggerated 
forms of incomplete lateral dislocations. In these 
latter accidents, as we have already noticed, the ex- 
ternal or the internal margin of the patella, accord- 
ing as the subluxation is to the outer or inner side, 
is thrown more or less obliquely forwards ; a position 
into which it is carried partly by the peculiar form 
of the articulating surfaces, and partly by the action 
of the vasti and rectus femoris muscles. If now these 
muscles were to contract suddenly and violently, and the return of the 



Dislocation of the 
patella inwards. 



DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 741 

patella to its normal position were prevented by the lodgment of one 
of its margins in the intercondyloidean fossa, the other or free margin 
would be compelled to rise until it became perpendicular to the limb, 
or it might perhaps even become completely reversed in its socket. 
The signs of the accident are such as to render an error in the diagnosis 
almost impossible. The limb is generally found forcibly extended, oc- 
casionally it is in a position of moderate flexion, but the projection of 
the sharp border of the patella directly forwards under the skin is itself 
sufficient to determine the true nature of the injury. 

Reduction may be effected by the same manoeuvres which we have 
recommended in lateral luxations ; but if these measures do not suc- 
ceed, we may direct the patient to make a violent effort himself to flex 
and extend the limb, or the surgeon may force the limb into flexion 
and extension alternately, or he may rotate the tibia upon the femur, 
and then flex. Finally, he ought to make use of lateral pressure also, 
upon both margins of the upright patella, but in opposite directions. 

In all cases it would be advisable to put the patient under the influ- 
ence of an anaesthetic before attempting reduction. In a case reported 
by Dr. H. Hunt, of Beloit, the reduction occurred spontaneously as 
soon as the patient was chloroformed, although it had resisted all the 
efforts previously made. 1 

Watson, of New York, has related the following example of rota- 
tion of the patella upon its inner margin (" Luxation Yerticale Ex- 
terne," Malg.) : 

Henry Burton, aged about thirty-five years, of rather slender frame, 
while riding on horseback in a crowd, received a blow upon his knee 
from a horse ridden by another person. When seen by Dr. Watson, 
soon after the accident, the leg was perfectly straight, but could be 
flexed to about an angle of 140° without causing pain. " The patella 
appeared to be slightly drawn up, and it was twisted upon its axis, 
presenting its outer edge, in a prominent hard line, in front of the 
knee; its inner edge was resting either in the groove between the 
condyles of the femur, upon which its posterior face should naturally 
play, or in the small depression on the anterior face of the femur, 
immediately above this groove. The anterior surface of the patella 
was turned inwards, its posterior surface outwards, and it rested nearly 
at right angles with its natural position. Its upper and lower attach- 
ments were both preserved, and could be distinctly felt ; and a sort of 
band appeared to pass from its under, or, as it now lay, its outer face, 
inwards to the deeper portion of the knee-joint. This band, as I con- 
ceived, was caused either by the tension of the capsular ligament, or 
by the rupture of its edge, as it passes from the outer side of the 
patella. The position of the bone was so well marked that no one at 
all acquainted with the anatomy of the part could mistake the nature 
of the accident. 

" With the leg extended, and the anterior muscles of the thigh 
forced downwards as much as possible, pressure was made upon the 
patella, with the expectation of forcing down its prominent edge. The 

1 H. Hunt, M.D., the Medical Kecord, April 1st, 1873. 



742 DISLOCATIONS OF THE PATELLA. 

effort was followed only by an increase of pain, the bone remaining 
permanently fixed. Another attempt was made to cant its posterior 
edge inwards, and to bring its anterior edge outwards, without press- 
ing it against the condyles of the femur, by forcing the head of a key 
against the posterior, now the outer, face of the patella (using this as 
a fulcrum), and pressing the prominent edge of the bone toward the 
outer condyle. This manoeuvre gave him no pain, but was as fruitless 
in its result as the other. At length the knee was forcibly bent and 
immediately straightened again ; and then, by canting the patella as 
before, and pushing it slightly downwards and inwards, it sprung with 
a sudden snap into its proper position." 1 

Dr. Joseph P. Gazzam, of Pittsburg, Pa., has met with a similar 
case. On the 10th of September, 1 842, James Porter was thrown while 
wrestling, and immediately found himself unable to rise. Dr. Gazzam 
saw him about an hour after the accident, and found the patella of the 
right leg dislocated on its axis, and resting on its inner edge in the 
groove between the condyles of the femur. Dr. G. proceeded to at- 
tempt reduction, but failed, after having made repeated trials by lift- 
ing the limb toward the body and by pressure in opposite directions. 
In consultation with Dr. Addison, it was now determined to divide 
the ligamentum patellae, which was done by introducing beneath the 
skin a narrow-bladed knife, and cutting close to the tubercle of the 
tibia. Again the attempts at reduction were renewed, but without 
success. The patella could be moved on its edge more freely than 
before the cutting, but resisted every effort to replace it. The patient 
was now bled in the erect posture and until the approach of syncope, 
but to no purpose. On the following morning it was determined to 
adopt, with some modification, the mode practiced so successfully by 
Dr. Watson. " The thigh was strongly flexed," says Dr. Gazzam, " on 
the pelvis, and the heel elevated. Then the leg was flexed steadily 
and forcibly on the thigh, and suddenly straightened. At the moment 
of straightening the leg, I pressed very strongly against the lower edge 
of the patella from without, with the head of a door-key well wrapped, 
while Dr. Addison pressed with both thumbs against the upper edge 
of the bone toward the external condyle. On the fourth trial this 
manoeuvre succeeded, the bone springing into its place with a snap." 
Recovery was uninterrupted, and two or three months after, the patient 
had the complete use of his limb. 2 

The following case is reported by Dr. S. F. Morris, New York : 

"Mr. B., aged 27, of slender build, while playing at ball, in en- 
deavoring to strike the ball had to jump up and turn partially round, 
when, on resuming his former position, he fell, his leg refusing to bend. 
He appreciated the nature of his injury, and, with the aid of the men 
in the store, endeavored to 'push it back/ Failing in this, surgical 
aid was sought, but, despite three attempts at reduction, the patella 
remained displaced. He was then taken to his home. 

" I saw him about two hours after the accident. He complained of 

1 Watson, New York Journ. Med., Oct. 1839, p. 302. 

2 Gazzam, Amer. Journ. Med. Sci., vol. xxxi, April, 1843, p. 363. 



DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 743 

severe pain when any manipulation was made. The leg was perfectly 
straight. The patella was firmly wedged (its outer edge) in the inter- 
condyloid fossa; its anterior surface looking outwards and slightly 
downwards, its posterior face looking inwards and upwards. The 
prominence of the edge of the patella, thus twisting on its longitudi- 
nal axis, left no doubt as to the diagnosis. 

" No attempt was made at reduction by me until the patient was 
etherized, when, assisted by Dr. C. M. Bell, of this city, it was easily 
performed in the following manner : The leg was raised from the bed, 
the thigh flexed on the pelvis. Dr. Bell then placed his thumb, as a 
fulcrum, beneath the under (posterior) surface of the patella, and pressed 
on the upper (anterior) surface; at the same time I slightly flexed, 
then suddenly extended and rotated the leg inwards. The patella im- 
mediately resumed its natural position. " x 

Dr. Sternberg, Assistant Surgeon U. S. A., has also published a case 
in the Medical and Surgical Reporter, reduced readily when the patient 
was under the influence of chloroform. I am unable to find the date 
of the record, but I think it was in 1869. 

The following case is reported by G. P. Davis, M.D., of Hartford, 
Conn. : 

" A few weeks ago I was summoned to a nurse-girl, who was re- 
ported to have ' put her knee out of joint.' On entering the room, I 
found the patient lying on her face, both legs extended, and the left 
foot pointing towards its fellow. 

" On turning the patient upon her back, the left patella was plainly 
seen in a condition of 'vertical' displacement, i. e., turned upon its 
inner edge, so that its upper surface looked toward the opposite knee. 
It was rigidly fixed, and the limb was entirely helpless. 

" I learned that while sitting upon the floor, playing with the baby 
under her charge, she suddenly reached forward, at the same time 
twisting her body partly around, in order to seize the child, who was 
a little out of her reach, and who, she feared, was about to fall. She 
immediately became conscious that an accident had befallen her knee. 

" The patient was etherized as she lay upon the floor. The whole 
limb was then elevated by an assistant, so as to relax the muscles in 
front of the thigh, and, by forcibly crowding down these muscles 
toward the knee with one hand, manipulating the patella at the same 
time with the other, reduction was effected with the utmost ease." 2 

April 1, 1875, through the courtesy of Dr. A. R. Robinson and of 
Prof. S. B. Ward, of this city, I was permitted to see a case of " semi- 
rotation" of the patella. The accident had happened the day before, 
in the person of Susan Newman, set. 31, a muscular Scotch woman, 
while wrestling. Dr. Robinson being called, attempted reduction by. 
pressure and by other means, but without success. About seventeen 
hours after the accident I found her in bed with the left leg extended 
upon the thigh, and the patella standing upon its inner margin, which 

1 Morris, New York Med. Kecord, May 15, 1869. 

2 Davis, Med. Eeeord, Dec. 1, 1874. 



744 



DISLOCATIONS OF THE PATELLA. 



rested in the intercondyloid notch. The patella was not vertical, but 
leaned over toward the outside of the knee. 

While placing her under the influence of chloroform, she bent her 
leg to a right angle, but the patella continued to occupy its abnormal 
position. When completely under its influence, Dr. Ward extended 
and flexed the leg with no result. He then tilted the patella down 
until it lay flat upon the outer condyle (this was the position it took 
also when, being partially chloroformed, she flexed the leg) ; and after 
a second attempt, with moderate pressure against the outer margin of 
the patella, it suddenly resumed its position. None of the tendinous 
or muscular attachments were ruptured. 

Dr. J. M. Boyd, of Thorntown, Indiana, reports a case of vertical 
dislocation ; the patella resting upon its internal margin, in a negro 38 
years old, and which was caused by muscular " spasms." Attempts 
were immediately made by a surgeon to reduce it, but without success. 
Subsequently Dr. Boyd tried also and failed ; but at the end of two 
weeks the muscular spasms returned, and before Dr. Boyd could reach 
the house the bone had resumed its position spontaneously. 1 Mai-' 
gaigne has reported, also, a case in the Gazette Medicale, for 1836, in 
which reduction was accomplished spontaneously during an attempt 
made by the patient to walk. The same writer refers to a case reduced 
under the influence of chloroform. Mr. Flower (Holmes's Surgery) 
records a similar case. 

In a case of the same kind, published originally in Rust's Magazine, 
and which is copied at length by Mr. B. Cooper in his edition of Sir 
Astley's great work, the reduction was found impossible, notwithstand- 
ing the surgeon finally had the temerity to sever completely the tendon 
of the quadriceps extensor, and the ligamentum patellae. Extensive 
suppuration followed, under which the poor fellow finally sank and 
died. 

I 4. Dislocations of the Patella Upwards. 

Occasionally the ligamentum patellar has been found so much elon- 
gated and relaxed, as to permit the patella to glide upwards upon the 
front of the femur. Heister and Ravaton have each seen an example 
in which a displacement from this cause existed to the extent of three 
inches. It is much more common, however, to meet with this disloca- 
tion as a result of a rupture of the ligamentum patellae, as the follow- 
ing example will illustrate. 

On the 18th of Dec, 1850, Dennis Mullards, set. 50, was admitted 
to the surgical wards of the Buffalo Hospital of the Sisters of Charity. 
While at work on this same day, he had slipped and fallen, with his 
knee forcibly flexed under his body. I found the ligament of the 
patella torn asunder, and the patella drawn up two or three inches 
upon the front of the thigh. We applied at once the dressings used 
by me for a broken patella, and were able to bring the bone down 
completely to its place. Three weeks from the time of the receipt of 
the injury the dressings were removed, and the patella was found to be 



Boyd, Western Journ. Med., May, 1868, p. 275, and June, 1868, p. 341. 



DISLOCATIONS OF THE HEAD OF THE TIBIA. 745 

nearly but not quite in its original place. From this time we com- 
menced to move the joint : in about ten days more he left the hospital, 
and I lost sight of him, so that I am unable to speak more definitely 
of the result. 

In February, 1869, Dr. George H. Smith consulted me in relation 
to a gentleman who had ruptured the ligament of the patella in both 
legs, a little more than a year before, by catching his heel in descend- 
ing from a carriage ; the ligaments giving way in the powerful muscular 
effort which he made to prevent himself from falling. 

Treated upon a single inclined plane in the same manner that I 
have recommended for a fractured patella, at the end of five weeks the 
patellae were in place and the ligaments reunited. After walking 
about one month upon crutches he caught the heel of his right foot 
again and again ruptured the ligament of the patella in the same leg. 
A similar plan of treatment failed to accomplish anything, and when 
he consulted me the patella was displaced three inches upwards. He 
could raise the leg slowly to a position of extension while sitting, and 
was able to walk four or five miles a day. 

Gibson has recorded a similar case, in which both patellae were dis- 
located upwards by a rupture of the ligaments, occasioned by the 
exercise of leaping. He recovered the use of his limbs almost com- 
pletely. 1 

(For examples of rupture of the quadriceps femoris, which some 
writers have incorrectly named Dislocations of the Patella Down- 
wards, see Velpeau's Surgery, 1st Amer. ed., vol. i, p. 422; New York 
Med. Times, April 6, 1861, p. 226, and two cases reported by myself 
in the same volume of the Med. Times.) 



CHAPTER XVIII. 

DISLOCATIONS OP THE HEAD OF THE TIBIA (FEMORO-TIBIAL). 

Syn — "Tibia upon the femur;" "dislocations of the leg." 

Ix consequence of the great size and irregularity of the articular 
surfaces between the tibia and femur, together with the remarkable 
number and strength of the ligaments which bind the two bones 
together, dislocations at this joint are exceedingly rare. They are- 
known to take place however, in four principal directions, namely r 
backwards, forwards, inwards, and outwards. A dislocation may also- 
occur in either of the diagonals between these points, that is, antero- 
lateral^ or postero-laterally. They may be either complete or incom- 
plete. Velpeau has found upon record thirteen examples of complete 
dislocations forwards and eight backwards, but not one of a complete 
lateral luxation. Velpeau thought, also, that the antero-posterior 

1 Gibson, Surgery, vol. i, p. 395, 6th ed. 
48 



746 



DISLOCATIONS OF THE HEAD OF THE TIBIA. 



Fig. 330. 



luxations were always complete, but Malgaigne has shown that this 
opinion is erroneous. 

Simple flexion and extension, however extreme, are generally insuf- 
ficient to produce either of these dislocations. They may be produced 
by a violent blow upon the lower end of the femur or upon the upper 
end of the tibia, or by twisting the tibia upon the femur, as when the 
foot is made fast in a hole, and the body swings around upon the knee. 

I 1. Dislocations of the Head of the Tibia Backwards. 

Symptoms. — The head of the tibia is felt in the popliteal space ; and, 
if the dislocation is complete, the pressure upon the popliteal nerve 
becomes excessively painful. 

A marked depression exists in front, immediately below the patella, 
and especially upon the sides of the ligamentum patellae; the condyles of 
the femur project strongly in front ; the leg may 
be not at all or only slightly shortened, or the 
shortening may amount to one inch or more, 
and usually it is in a position of extreme exten- 
sion, or thrown forwards from the line of the 
axis of the femur; but its position has been 
found to vary greatly in different cases, the 
limb being sometimes very much flexed, and in 
others very slightly flexed, or perfectly straight. 
Pathological Anatomy. — The posterior liga- 
ment of the joint is torn ; the muscles of the 
ham are put upon the stretch ; the popliteal 
nerves and vessels compressed ; and the head of 
the tibia either rests partly upon the posterior 
half of the lower articulating surface of the 
femur, or it passes up and rests only against its 
posterior articulating surface, which in this 
direction extends an inch or more upwards. If 
the dislocation is complete, the crucial liga- 
ments are also torn, and all the parts about the 
joint suffer extensive injury from stretching, laceration, or compression. 
Prognosis. — Malgaigne has seen three examples of incomplete back- 
ward luxations which were not reduced, and neither of the persons 
was very greatly maimed in consequence. One walked with crutches 
after three or four days, and with a cane after about five weeks. 
Another did not leave his bed under one month, and it was nearly 
one year before he could lay aside his crutches ; but both of them were 
finally able to walk at least twelve leagues per day. Malgaigne in- 
forms us, however, that in a similar case seen by Lassus, the patient 
was confined to his bed two years, although he finally recovered a tol- 
erable-use of his limb. 

If the reduction is promptly effected, the limb kept perfectly quiet a 
sufficient length of time, and in other respects properly managed, not 
much inflammation need generally be anticipated, and the limb may 
suffer in the end very little if any maiming. 

Treatment. — It will be proper, at first, to attempt the reduction by 




Dislocation of the head of the 
tibia backwards. 



DISLOCATIONS OF HEAD OF TIBIA BACKWARDS. 747 

simple manipulation, as this is often found to succeed when the dislo- 
cation is recent and incomplete, and especially when the system is 
greatly depressed by the shock of the injury. If the dislocation is 
complete, however, we can hardly anticipate success without the appli- 
cation of some extending force. 

In the employment of manipulation we ought to be governed at first 
by the same rule which we have found so generally applicable in dis- 
locations of the femur, namely, to carry the limb in those directions in 
which it will move easily, or without much force. If this fails, we 
may at once resort to forced flexion alternating with extension, rotating 
or rocking the limb also occasionally from one side to the other, while 
at the same moment strong pressure is made upon the projecting bones 
at the knee-joint in opposite directions or in the direction of the articu- 
lation. 

Finally, it may be necessary to resort to extension, made by means 
of a lacq, or by the hands of strong assistants, above the ankle, always 
at first in the direction of the axis of the tibia ; the counter-extending 
band being applied to the perineum if the leg is straight, but to the 
lower and back part of the thigh if the leg is flexed. 

A very convenient mode of making extension, where we wish to 
apply more than usual force, is to lay the whole limb over a firm 
double-inclined plane, or fracture splint, securing the thigh to the 
thigh-piece with a roller, and making the extension with the screw 
attached to the foot-board. This method, however, while it enables 
us to use great force in the extension, prevents the surgeon from em- 
ploying, at the same time, those flexions, extensions, and other manipu- 
lations, upon which success so often depends. 

Dr. James Carmichael has reported a case in which reduction was 
effected easily by flexion, when traction had failed. 1 

Mr. Rose has related, in the Provincial Medical Journal of June 11, 
1842, a characteristic example of this accident, except that the patella 
had also suffered a lateral displacement, presenting the usual favorable 
termination. 

A woman was standing upon a low ladder, when a carriage driven 
furiously came in contact with it, and precipitated her to the ground. 
Mr. Rose, who saw her almost immediately, found the tibia completely 
dislocated at the knee, the head being driven behind the condyles of 
the femur into the ham, with the patella thrown to the outside of the 
external condyle, and the leg in a state of fixed extension. Immedi- 
ately, and without difficulty, the bones were restored by applying one 
hand to the patella, the other to the back of the upper portion of the 
tibia, and simultaneously pulling and pushing those bones toward their 
natural positions. The patient was then removed to a bed, and by the 
diligent use of antiphlogistic remedies inflammation was kept in check, 
and the case reached a favorable termination without one untoward 
symptom. After the lapse of only a few weeks, she had completely 
recovered the use of the knee-joint. 2 

1 New York Med. Gazette, Aug. 22, 1868; from the Lancet. 

2 Rose. Amer. Journ. Med. Sei., vol. xxxi, p. 216. 



748 



DISLOCATIONS OF THE HEAD OF THE TIBIA. 



Dr. Walsham communicated a case to Sir Astley Cooper, in which 
the dislocation was not only complete, but the tendon of the quadri- 
ceps extensor was ruptured. The leg was bent forwards. The reduc- 
tion was accomplished very easily by extension made with the hands 
by four men, in the line of the axis of the limb. In about one month 
this man began to walk with crutches, but he was not perfectly recov- 
ered until after five months; at which time the crutches were finally 
laid aside. 1 



2. Dislocations of the Head of the Tibia Forwards. 






Fig. 331. 



The signs of this accident are the reverse of those which belong to 
dislocations backwards. The patella, tibia, and fibula are prominent 
in front, while the condyles of the femur may be felt behind, pressing 
strongly upon the muscles,, nerves, and bloodvessels which occupy the 
popliteal space. In case the dislocation is complete, a shortening may 

exist to the extent of one or even three 
inches. Dr. O'Beirne, of Dublin, has men- 
tioned a case to Mr. B. Cooper, in which 
the shortening was three inches and a half, 
and Mr. Mayo has seen one example in 
which the dislocated limb was "fully four 
inches" shorter than the other. 2 

In consequence of the pressure upon 
the popliteal artery, the pulsations in the 
branches below are frequently interrupted, 
and in one instance this pressure was suf- 
ficient to produce finally a dry gangrene. 

Dr. Gorde relates a case in the Bulletin 
de Therapeutique, occurring in a woman 
nearly sixty years old. This woman was t 
returning home at night with a heavy 
burden, and in a state of intoxication, 
when she stepped into a ditch as deep as 
up to the middle of her thighs. The body 
was thrown forwards by the fall, while the 
feet stuck at the bottom of the ditch ; the whole force of the impulse 
being sustained by the thighs. The lower end of the femur was found 
driven downwards and backwards, and lodged under the muscles of 
the calf of the leg; the limb being shortened three inches. Reduction 
was promptly effected, and without inflicting any pain of which the 
patient complained. In six weeks the patient was cured. 3 

Mr. Toogood has reported also, in the Provincial Medical Journal of 
June 18th, 1842, an example of complete dislocation in this direction, 
in which the appearance was so dreadful, that Mr. Toogood at first 
despaired of being able to reduce it; but by directing two men to 
make counter-extension while he made extension, the reduction was 




Incomplete dislocation of the head of 
the tibia forwards. 



1 Walsham, Sir A. Cooper on Disloc , etc., 2d Lond. ed., p. 188. 

2 B. Cooper's ed of Sir Astley Cooper on Disloc , etc., pp. 214-215. 

3 Gorde, Amer. Journ. Med. Sci., vol. xvi, p. 2_'5, May, 1835. 



DISLOCATIONS OF HEAD OF TIBIA FORWARDS. 749 

immediately effected. At the end of one month the patient was able 
to leave his bed ; and sixteen years after, Dr. Toogood saw him walk- 
ing "with very little lameness." 1 Parker, of Liverpool, has reported 
another example in the London and Edinburgh Monthly Journal for 
December, 1842, which was occasioned by the fall of a heavy spar 
upon a man's back, and the consequent violent bending of the knee 
under his body. In this case the limb was slightly flexed, and the 
patella was loose and floating. The reduction was effected without 
much difficulty by extension and counter-extension made by two men, 
while the operator, placing his knee in the ham of the patient, attempted 
to bring the leg to a right angle with the thigh. 2 

B. Cooper, Malgaigne, Little, 3 and others, have recorded examples 
of this accident. 

March 9th, 1865, Hiram Wescott, of Sandy Cove, Xova Scotia, set. 
45, was caught by his sled, drawn by horses, in such a way that a 
beam pressed against the front and lower end of the femur while the 
heel was caught and arrested by a stump. The foot was thrown for- 
wards and the upper end of the tibia completely dislocated in the same 
direction. It was at once reduced by a person who was present, but 
on attempting to use the leg in walking it was reluxated immediately. 
Mr. J. H. Harris, medical student, found the limb soon after completely 
luxated, with the leg thrown forwards in the position of dorsal flexion 
about 40°. The tendons of the hamstring muscles were not ruptured, 
but had slid forwards past the condyles of the femur. There was no 
external wound. Reduction was easily accomplished by simple exten- 
sion. Pasteboard splints were then applied. On the third day the 
knee w r as considerably swollen, and some ecchymosis existed about the 
popliteal region. On the fifth day these symptoms had much increased. 
Mr. Harris then applied extension to the foot, with the aid of adhesive 
plaster, pulley and weights, and by elevating the foot of the bed. The 
amount of extension employed was 9 lbs. This gave immediate relief 
to the pain, and was continued until the inflammation subsided. His 
recovery was steady, and in four months he walked with crutches or a 
cane. 

In 1864 a similar dislocation was presented at the Brooklyn City 
Hospital, in which reduction having been practiced, the patient died. 
The case is reported very fully by Dr. Le Roy M. Yale. 4 

Dr. White, of Buffalo, politely invited me to see w T ith him a lad, aet. 
10, whose tibia had been partially dislocated forwards eight weeks 
before, by a boy's having hit the top of his knee with his head, while 
they were at play. His father, who is himself a physician, residing 
near town, reduced the limb very easily, by extension made with his 
own hands, and by pressing upon the projecting bones. Violent in- 
flammation ensued, but at the time when I saw him, the knee was free 
from soreness or swelling, and the motions of the joint were nearly 
restored. 

Dr. Charles S. Downes, of Mclndoe's Falls, Vt., has sent me the fol- 

1 Toogood, Araer. Journ. Med. Sci., vol. xxxi, p. 465. 2 E. Parker, ibid. 

3 Little. New York Med Times, Au?. 17, 1861. 

4 Yale, New York Journ. Med., vol. ii, p. 124, Nov. 1865. 



750 



DISLOCATIONS OF THE HEAD OF THE TIBIA, 



lowing account of a case which occurred in his own practice. October, 
1861, Mrs. H., a robust young married woman, aged about 20 years, 
was driving a young horse and holding her infant in her arms, when 
the horse ran and she was thrown out. One of her legs being caught 
in the wheel, she was carried over three or four times in its revolutions 
before she became disengaged, holding meanwhile upon her infant with 
such firmness that it suffered no harm. 

A few hours later Dr. Downes and Dr. Burton found a complete 
dislocation of the tibia and fibula forwards, and the lower end of the 
femur could be felt under the muscles of the calf of the leg. The limb 
was shortened four inches and a half. The patella lay loosely in front 
of the femur, with its lower margin tilted forwards. 

The patient was laid upon a bed, and a perineal band made fast to 
one of the posts, while a lacq was placed upon the foot and attached to 
a rope folded upon itself and forming a pulley or "Spanish windlass," 
such as is described at page 690. In this way the reduction was 
speedily and easily accomplished. Hot fomentations were subsequently 
applied for several days, the limb being kept perfectly at rest. In 
about three months she was able to do her own housework, and in a 
short time after all traces of her accident had disappeared. 

The following account of a case was sent to me by my young friend, 
Dr. Alonzo Pettit, of Elizabethport, N. J. : 

"Joseph McGuire, laborer, set. 26, was stealing a ride upon a freight 
train upon the Central Railroad of New Jersey, on the evening of 
June 19th, 1874. He was sitting upon the platform of the car, with 
his feet upon the platform of the next car, his legs extended. The 
train slacking up at a station, before he had time to bend his knees, 
the cars came together and pushed the head of the left tibia upwards 
upon the femur. 

"I saw him about half an hour after the accident, and found a com- 
plete dislocation of the head of the tibia, with the patella forwards upon 
the femur. The leg was slightly flexed, and shortened two and a half 
inches. I succeeded in reducing it easily without assistance, or the use 
of anaesthetics, by grasping the leg with the left hand, the right being 
in the popliteal space, making moderate extension and flexion, and 
pressing upon the condyles of the femur. There was considerable 
swelling and inflammation, but they yielded under the use of refrigerant 
lotions. The leg was kept extended for three weeks, during which 
time he suffered no pain whatever. At the end of two weeks I began 
the use of passive motion, cautiously, and after three weeks I allowed 
him to begin to walk, wearing a firm elastic knee-cap. July 22d,when 
I last saw him, he walked with a very slight halt, and could bend the 
knee about 25°, and was still improving." 



I 3. Dislocations of the Head of the Tibia Outwards. 

Occasionally, owing to a violent wrench of the knee-joint, the lateral 
ligaments upon one side or the other are ruptured, and consequently 
the joint surfaces separate somewhat from each other; or when the 
limb is moved, the head of the tibia may slide a little forwards or back- 



DISLOCATIONS OF HEAD OF TIBIA OUTWARDS. 



751 



Fig. 332. 



wards, or to either side. These are not properly examples of sublux- 
ation ; nor should we consider as belonging to this class the accident 
originally described by Mr. Hey as an " internal derangement of the 
knee-joint," but which also by some writers has been termed a " sub- 
luxation of the knee." Of this latter accident I will take occasion 
hereafter to speak a little more particularly. 

In subluxation, properly so called, if the direction of the dislocation 
is outwards, the outer condyle of the femur rests upon the inner artic- 
ulating surface of the tibia, and if the direction of the dislocation is 
inwards, the inner condyle of the femur rests upon the outer articulat- 
ing surface of the tibia. 

The signs which characterize this accident are such as cannot easily 
be mistaken. The limb is not shortened, nor is there anything espe- 
cially diagnostic in its position, since it has been found to be some- 
times flexed, and at other times straight; but the strong lateral pro- 
jections made by the inner condyle of the femur on the one hand, and 
by the heads of the tibia and fibula on the other, cannot fail to inform 
us as to the true nature of the accident. 

The treatment will not differ essentially from that which has already 
been recommended in dislocation of the tibia backwards or forwards. 
If any other expedients can prove useful, they must 
be left to the judgment of the surgeon whenever 
the exigencies of the case shall demand them. 

I have already mentioned the case of N. Smith, 
who, in consequence of a fall from a window, had 
a dislocation of the right femur, tibia, and patella. 
The tibia was subluxated outwards, and the leg 
was partially flexed upon the thigh, with the toes 
everted. By moderate extension, made with my 
own hands, united with alternate flexion and ex- 
tension, the bone was easily and promptly restored 
to its place. Having reduced the femur also, the 
limb was laid over a gently inclined plane made of 
pillows ; and cloths moistened with cool water were 
kept constantly applied to the knee for many days. 
Very little swelling followed the accident, and his 
recovery was rapid and complete. 

A man was received into the North London Hos- 
pital, with a partial dislocation of the tibia outwards, 
and although the knee was much swollen, the na- 
ture of the injury was easily determined. The 
knee was immovable, and the toes turned outwards, 
house surgeon, reduced it by extension and counter-extension made by 
his own hands. 1 

Mr. Pitt records a similar case in a young lady, produced by a fall 
down a flight of stairs. It was reduced easily by extension and coun- 
ter-extension. Inflammation followed, but it was finally controlled, 
and she regained the use of her limbs. 2 




Subluxation of the head 
of the tibia outwards. 



Mr. Hallam, the 



1 Hallam, Amer. Journ. Med. Sci., vol. xix, p. 251. 

2 Pitt, ibid., vol. xxxi, p. 465. 



752 



DISLOCATIONS OF THE HEAD OF THE TIBIA. 



In one case of subluxation, mentioned by Sir Astley Cooper, and in 
a second recorded by Bransby Cooper, the recovery of the functions of 
the joint did not seem to have been so rapid; the joint remaining 
unstable and tender for a long time afterwards. 1 

\ 4. Dislocations of the Head of the Tibia Inwards. 

There is nothing peculiar in either the signs, condition, or treatment 
of this accident, as distinguished from a dislocation outwards, to de- 
mand of us a special consideration. 

Sir Astley Cooper has mentioned two cases of subluxation inwards, 
and Mr. B. Cooper has added to these a third. Sir Astley remarks 
that in the first accident, the only one indeed which he had himself 
ever seen, he was struck with three circumstances : first, the great 
deformity of the knee from the projection of the tibia ; second, the 
ease with which the bone was reduced by direct extension ; and third, 
by the little inflammation which followed. The second case of which 
Sir Astley speaks was communicated to him by a Mr. Richards. In 
this case the fibula was also broken, and the reduction was accom- 
plished only after extension had been made by 
fig. 333. several persons for half an hour. The limb became 

excessively swollen, and remained so for many 
weeks. Eighteen months after the accident the 
knee continued somewhat stiff, and there was an 
unnatural lateral motion in the joint, from the in- 
jury which the ligaments had sustained. The pa- 
tient referred to by Bransby Cooper had met with 
the accident by a fall upon the foot, with his leg 
bent under him ; and a fellow-workman had re- 
duced the bone by extension and pressure. Mr. 
Cooper thinks that not only the internal lateral 
ligament was torn, but also some fibres of the vas- 
tus extern us and the crucial ligaments. Violent 
inflammation ensued, which did not permit him to 
leave the hospital until after about two weeks. 2 
Fergusson has seen two examples of unreduced 
subluxation inwards, in both of which the patients 
had regained useful limbs. 3 

Malgaigne mentions that Boyer, Costallat, and 

Key had each seen one similar example; and he 

also enumerates two additional cases of complete luxation attended 

with a protrusion of the bone through an external wound ; in both of 

which the reduction was easily effected and the patients recovered. 4 




Subluxation of the head 
of the tibia inwards. 



\ 5. Dislocations of the Head of the Tibia Backwards and Outwards. 
In June, 1853, Henry J., of Dansville, IS". Y., set. 24, was thrown 



1 E Cooper's ed. of Sir Astley, op. cit., pp. 111-13. 

2 Ibid. 

3 Fer^u^son, op. cit , p. 284. 

4 Malgaigne, op. cit., torn, ii, p. 956. 



DISLOCATIONS OF HEAD OF TIBIA INWARDS. 753 

by an enraged bull, and his left leg being caught under the knee by 
the horns, was twisted violently. Dr. Prior, of Dansville, and Batton, 
of Burns, were called, and found the left knee completely dislocated ; 
the tibia being displaced backwards beyond the condyles of the femur, 
and also a little outwards. The foot and leg were inclined outwards. 
With the assistance of four men, extension and counter-extension were 
made in the line of the axis of the limb, and the reduction was easily 
accomplished. Pasteboard splints, bandages, etc., were applied to 
maintain the bones in place; but the swelling came on rapidly, and in 
the evening these dressings were removed. The limb was now laid 
over a double-inclined plane carefully padded, in order to press the 
upper end of the tibia forwards, as it manifested a constant inclination 
to become displaced backwards. This apparatus was employed six 
weeks, with the exception of two or three days, during which the 
limb was laid upon pillows, but as the pillows did not sufficiently 
support the back of the tibia, the double-inclined plane was resumed. 
After the removal of the plane, during seven weeks longer, an angular 
splint was kept closely applied to the back of the limb. 

Seven months after the accident, on the 23d of January, 1854, Dr. 
Robinson, of Hornellsville, brought the gentleman to me. I found the 
bones displaced backwards about three-quarters of an inch, and half 
an inch outwards, or to the fibular side. This was the position of the 
bones when he was sitting with his leg bent at a right angle with the 
thigh, but when he stood erect and bore some weight upon the foot, 
the outward displacement ceased, and the backward displacement only 
remained. It was very easy, however, in whatever position the leg 
might be, to push the bones forwards by the hands until nearly all 
deformity had disappeared. He could flex the leg to a right angle 
with the thigh, and straighten it completely, but he could not lift the 
foot and leg from the floor while sitting with his limb extended in 
front of him. He was unable to bear sufficient weight upon his foot 
to use it at all in progression, on account of the inability to fix and 
steady the limb, but not on account of any pain or soreness which it 
occasioned. 

It was very plain that the surgeons w r ere not in fault for this unfor- 
tunate condition ; indeed, they seem to have exercised throughout great 
ingenuity and skill in its management. 

I directed the young man to Mr. John C. Seiffert, of Buffalo, a very 
ingenious instrument-maker, who has since succeeded, I learn, in 
adapting to his knee a mechanical contrivance which enables him to 
walk quite well. 

Thomas Wells, of Columbia, South Carolina, has described a similar 
accident, the tibia being dislocated outwards and backwards, which 
terminated fatally on the fourth day in consequence mainly of expo- 
sure, intemperance, and neglect to apply for surgical aid. The bones 
were never reduced, and the autopsy disclosed also a fracture of the 
internal condyle of the femur. 1 

1 Wells, Araer. Journ. Med. Sci., vol. x, p. 25, May, 1832. 



754 DISLOCATIONS OF THE HEAD OF THE TIBIA. 



\ 6. Internal Derangement of the Knee-Joint. 

Syn. — "Slipping of the semilunar fibro-cartilages;" Hey. "Partial dislocation 
of the thigh-bone from the semilunar cartilages;" Sir Astley Cooper. " Subluxa- 
tion of the semilunar cartilages ;" Malgaigne. "Subluxation of the knee;" Erich- 
sen. To these we think it proper to add, as giving rise to the same class of symp- 
toms, " Floating cartilages in the knee-joint." 

We have already expressed our opinion that this accident is in no 
proper sense a subluxation of the knee ; and we should not, therefore, 
think it worth while to make any farther allusion to it, were it not 
necessary in order to enable the student of surgery to distinguish be- 
tween the phenomena which belong to it and those which belong 
strictly to subluxation of this joint. 

Symptoms. — The patient is suddenly thrown to the ground while 
walking, as if by an instantaneous loss of power in the affected limb, 
this loss of control over the limb being accompanied usually with 
sharp pain, referred to the region of the knee-joint ; or he trips his toe 
against something in his path, and the toes becoming everted, the leg 
suddenly gives way under him ; in some cases it has happened when 
the patient was turning in bed, the weight of the bed-clothes hanging 
upon the toes so as to occasion a strain and rotation outwards at the 
knee-joint, or it follows upon a subluxation of the joint, as in one 
example which I shall presently relate. 

If the patient is walking when the accident takes place, and he falls 
to the ground, he finds himself unable to move the limb, or to stand 
upon it ; but by manipulation, the difficulty is, in most cases, as easily 
overcome as it occurred, when immediately the motions of the joint 
become free, and he walks off as if nothing had happened. 

When the accident has once taken place, it is afterwards exceedingly 
liable to occur from very slight causes, and eventually the knee-joint 
becomes tender and the capsule fills with synovia, indicating the exist- 
ence of subacute synovitis. 

A single example will illustrate the usual history of these cases. 

A young man, from Colesville, N. Y., set. 23, consulted me, on the 
27th of Oct. 1858, in relation to the condition of his knee-joint. He 
stated that on the 13th of Aug. 1858, while standing with the whole 
weight of his body resting upon the left leg, a mate struck him on the 
inside of the lower end of the left femur. The blow was made with 
the palm of the hand, but with sufficient force to throw him down. It 
was immediately noticed that the tibia was partially dislocated inwards 
at the knee-joint. The whole lower part of the limb was inclined 
outwards. A person present in the room seized upon the foot and by 
extension easily brought it back to place ; the bone resuming its posi- 
tion with an audible snap. After this he continued to walk about 
until night. Two days after, the knee had become so much inflamed 
that he was obliged to take to his bed, on which he was confined three 
weeks. Gradually the swelling subsided, and in about five weeks after 
the accident he began to walk on crutches. On the 23d of Sept., he 
was walking in the store without crutches, when he suddenly felt a 
sensation of slipping in the joint, and he fell to the floor as if he had 



INTERNAL DERANGEMENT OF THE KNEE-JOINT. 755 

been tripped up. At the time when he called upon me, this had hap- 
pened many times, but had never been attended with pain. The joint 
was filled with synovia, and tender, yet I could distinctly feel a hard 
body just to the inside of the ligamentum patellae, and which moved 
freely under the finger. 

Pathological Anatomy. — The same class of symptoms, with only 
very slight modification, belongs probably to several varieties of " in- 
ternal derangement of the knee-joint;" and first it will be remembered 
that the semilunar cartilages upon which the margins of the condyles 
of the femur rest, are attached to the tibia by several ligaments ; but 
when, from relaxation or a violent strain, any one of these ligaments 
becomes elongated or gives way, the portion of cartilage which it re- 
strains is permitted to become partially displaced, and by interposing 
its thick margin between the deeper articulating surfaces the bones are 
separated and the muscles lose their control over the joint; second, 
these ligaments may not only yield, but a fragment of one of the car- 
tilages may become actually broken off from the main portion ; third, 
the femur may perhaps escape behind some portion of an interarticular 
cartilage, and thus, instead of the cartilage placing itself between the 
joint surfaces, the femur itself may have thrust it into this position ; 
fourth, a cartilage or some portion of a cartilage may become hyper- 
trophied, and thus give rise to the symptoms described ; fifth, in other 
cases still, a bony, cartilaginous, fibrinous, or calcareous growth or 
concretion forming within the joint, and, if originally attached, becom- 
ing separated from the capsule, may move about more or less freely, 
and give rise to the same class of symptoms which we have described. 

This last variety has generally been described under the name of 
" floating cartilages ;" but since these bodies are not always cartilagi- 
nous, and especially since they do not always by any means move so 
freely as to be properly designated as "floating," the term is less 
appropriate than that originally given by Hey, and which we have 
chosen to adopt. 

Treatment. — For the purpose of obtaining immediate relief, it is 
generally sufficient to flex the leg completely and then suddenly extend 
it, or to combine this motion with a slight twisting or rocking of the 
knee-joint. Sometimes this experiment has to be repeated several 
times before it is completely successful, and in a few instances it has 
failed altogether. I think I must have met with ten or twelve ex- 
amples in the course of my practice, and in no instance has the sudden 
flexion and extension of the limb failed to overcome the difficulty. 

As to the question of subsequent treatment, especially as to whether 
it is proper to attempt their extirpation when they are found to be 
loose, or to make any other surgical interference, I prefer to leave its 
consideration to those general treatises upon surgery where it more 
properly belongs. 



756 DISLOCATIONS OF LOWER END OF THE TIBIA. 






CHAPTEE XIX. 

DISLOCATIONS OF THE LOWER END OF THE TIBIA (TIBIO- 

TARSAL). 

Syn. — " Dislocations of the ankle-joint ;" Chelius and others. 

The tibia may be dislocated at its lower end in four directions ; 
namely, inwards, outwards, forwards, and backwards. Most of these 
dislocations complicate themselves with fractures of the fibula or of 
the tibia, or with fractures of both bones. 

Dupuytren, Malgaigne, and a few other surgeons have reported ex- 
amples also of dislocations forwards and inwards. 

Boyer, with a majority of the French writers, and several English 
and German surgeons, speak of these dislocations as belonging to the 
foot; consequently the outward dislocation of Boyer is the inward 
dislocation of Sir Astley Cooper, Malgaigne, myself, and others, who 
prefer to regard the tibia as the bone dislocated. 

I 1. Dislocations of the Lower End of the Tibia Inwards. 

Syn — "Inward tibio-tarsal luxations;" Malgaigne. " Dislocations of the foot 
outwards;" Boyer and others. 

Causes. — This dislocation is occasioned generally by a fall from a 
height, upon the bottom of the foot, the foot receiving at the same 
moment a sufficient inclination outwards to determine the main force 
of the impulse toward the inner side of the ankle. It may be pro- 
duced also by a blow received directly upon the outside of the leg 
just above the ankle, or by a violent twist or wrench of the foot out- 
wards. 

Pathological Anatomy. — I have already, in the chapter on fractures 
of the fibula, stated my opinion that a large majority of those accidents 
which have been called inward and outward dislocations of the tibia, 
were merely examples of lateral rotation of the astragalus within the 
half ginglymoid and half orbicular socket formed by the lower ex- 
tremities of the tibia and fibula; and that true dislocations, either par- 
tial or complete, are at this joint and in these directions very rare oc- 
currences. We shall continue, however, in accordance with the general 
practice of writers, to call them all dislocations, whether the astragalus 
simply rotates on its axis, or is displaced laterally and horizontally 
from the tibia. 

In the most common form of the accident, then, when the foot is 
violently twisted outwards, the astragalus becomes tilted upon its outer 
and upper margin in such a way as that this margin slides inwards 
and places itself underneath the middle portion of the lower articulating 




DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 757 

surface of the tibia ; its upper and inner margin descends toward the ex- 
tremity of the malleolus inter- 
ims, and the outer face of the fig. 334. 
astragalus presents obliquely 
upwards and outwards, instead 
of directly outwards as it w T ould 
do in its natural position. This 
cannot occur without a rupture 
of the internal tibio-tarsal liga- 
ments, or a fracture of the mal- 
leolus intern us, or both ; indeed, 
a fracture of the internal mal- 
leolus is a very common cir- 
cumstance in connection with 
this form of dislocation. Much 

more frequently however the Dislocation of the lower end of the tibia inwards. 

fibula itself gives way at a point 

within from two to five inches of its lower extremity; or sometimes the 
fracture in the fibula occurs through that portion which forms the mal- 
leolus externus. For more particular information as to the causes and 
relative frequency of these fractures, I refer the reader to the chapter 
on fractures of the fibula. 

Rarely it happens that, instead of this lateral rotation of the astrag- 
alus, there occurs a true lateral displacement of the tibia inwards upon 
the astragalus, and the outer portion of the lower articulating surface 
of the tibia comes to rest upon the inner portion of the upper articu- 
lating surface of the astragalus ; or it may slide completely off in the 
same direction ; a result which is usually attended w T ith a laceration of 
the muscles and integuments, converting the accident into a compound 
dislocation. In some cases this extreme displacement occurs without 
such lacerations. 

In this form of the accident, the true lateral luxation, the fibula 
may remain unbroken and undisturbed, the tibia merely having be- 
come displaced inwards ; or the fibula may g^ive way also above the 
articulation, while the malleolus internus, and the internal lateral 
ligaments, are equally liable to rupture as in the other form of the 
accident. 

Sometimes, in addition to these complications, the lower end of the 
tibia is found to be broken obliquely upwards and outwards from the 
articulating surface, leaving that fragment attached to the fibula which 
corresponds to the inferior peroneo-tibial articulation. 

Symptoms. — The foot is more or less violently abducted, the sole of 
the foot presenting downwards and outwards instead of directly down- 
wards; the malleolus internus projects strongly at the inner side of 
the joint ; and at the outer side there is a corresponding depression, 
generally most marked a little above the articulation near the point 
of fracture in the fibula. The pain is very great, and the foot is im- 
movably fixed so far as the volition of the patient can determine 
motion, but the surgeon can generally move it pretty freely, yet not 
without causing a great increase of the pain. When the dislocation 



758 DISLOCATIONS OF LOWER E 



5ND OF THE TIBIA. 



is complete, and the fibula also is broken, the limb becomes slightly 
shortened. 

Treatment. — When the accident is of the nature of a simple rotation 
of the astragalus upon its axis, the reduction is often accomplished 



Fig. 335. 







Dislocation of the lower end of the tibia inwards. 

with the greatest ease by seizing upon the foot and forcibly adducting 
it. Not unfrequently the patient himself, or some other person who 
is present, has effected the reduction before the surgeon is called. In 
other cases, and especially when it partakes of the nature of a true 
dislocation, much difficulty is sometimes experienced in the reduction. 
The surgeon ought then to flex the leg upon the thigh, in order to 
relax the gastrocnemii muscles, and holding the foot midway between 
flexion and extension, he should pull steadily upon it with his own 
bands, while an assistant makes counter-extension and supports the 
limb with his hands, grasping the thigh above the knee. At the same 
moment lateral pressure should be made upon the projecting bone in 
the direction of the articulation. It is of some use, also to occasion- 
ally flex and extend the limb moderately, and to give to the foot a 
gentle rocking motion. If more force is needed, it may be applied 
by placing the limb over a firm double-inclined fracture-splint, and 
making the extension by the aid of a screw attached to the foot-board, 
as we have suggested in certain cases of dislocation at the knee. Or 
we may employ the pulleys after the manner represented in the accom- 
panying drawing, Fig. 336. 

Charles Sauer, aged about 30 years, while carrying a weight upon 



DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 759 

his shoulders, on the 6th of May, 1854, slipped upon the sidewalk, 
and fell, dislocating the left tibia inwards, and fracturing the fibula 
four inches from its lower end. I was in attendance soon after the 
accident occurred, and found the tibia projecting inwards, with the 
other symptoms usually accompanying a simple rotation of the astrag- 
alus upon its axis. Seizing the foot with my hands, and flexing the 
leg, while an assistant held up the thigh and made counter-extension, 



Fig. 336. 




I had scarcely begun to pull upon the foot before the reduction was 
effected. Dupuytren's splint was at once applied, and the subsequent 
inflammation was so trivial as scarcely to deserve notice. In six weeks 
the limb was sound, and free from all anchylosis. 

In my report on dislocations, made to the New York State Medical 
Society for the year 1855, I have mentioned twelve similar examples, 
in addition to some examples of compound dislocations, all of which 
were easily reduced, but the results were not always so favorable. 

If, as rarely happens, the tibia is broken obliquely into the joint, 
the complete reduction of the dislocated tibia may be found impos- 
sible, owing to the obstacle presented by the displaced fragment. 

The following I am disposed to regard as examples of dislocation 
accompanied with fracture of the tibia within the articulation : 

Brockway, of Cortland, N. Y., aged about twenty-seven years, con- 
sulted me, at my office, a few years since, in relation to the condition of 
his foot. I found the tibia dislocated inwards, and projecting more 
than an inch beyond the astragalus ; the sole was turned outwards, 
compelling him to walk upon the inside of his foot ; the fibula w T as 
bent inwards against the tibia, at a point about four inches above the 
ankle, which seemed to have been the seat of fracture of this bone. 
He stated to me, that immediately after the receipt of the injury, 
which was occasioned by a fall from a height upon the bottom of his 
foot, he had consulted a surgeon, Dr. A. B. Shipman, of Cortland, and 
that although Dr. Shipman made repeated and violent efforts to effect 
the reduction, he had been unable to do so. Indeed, the bone had 
never been removed from the position in which it was at first placed. 



760 DISLOCATIONS OF LOWER END OF THE TIBIA. 

J. Borland, of Erie Co., N. Y., set. 31, fell under a rolling log, 
dislocated his left tibia inwards, breaking off the internal malleolus, 
and fracturing the fibula four inches from its lower end. Dr. Sweet- 
land, an old and experienced practitioner, was immediately called, 
who, with another surgeon, failed, after repeated efforts, to reduce the 
dislocation. I saw the patient, in consultation with these gentlemen, 
twenty-four hours after the accident. The foot and ankle were some- 
what swollen and discolored. The lower end of the tibia projected 
so far inwards as to threaten a rupture of the skin ; the foot was 
strongly everted. We first flexed the leg upon the thigh, and made 
extension with our hands, in the manner I have already directed. 
This we continued several minutes; finally moving the limb in various 
directions, and adding 'forcible pressure upon the inside of the pro- 
jecting tibia. We then placed the leg over a double-inclined plane, 
and, securing it firmly in place, we attached a screw to the foot through 
a sandal and gaiter, and while the leg was well flexed upon the thigh, 
we renewed the extension and lateral pressure. This was continued, 
with the application of more or less power, during half an hour, mean- 
while changing the position of the limb occasionally by varying the 
angle of the splint. Our efforts were prolonged in all more than one 
hour, when, as we had made no impression upon the bone, and the 
patient had repeatedly implored us to desist, the attempt was given 
over. The end of the tibia seemed to rest partly upon the astragalus, 
and the extension was plainly all that was demanded, but the obstacle 
was beyond doubt within the articulation, or rather between the tibia 
and fibula. 

Four weeks after the accident, Mr. Borland walked on crutches, 
and during a year he was compelled to use a cane, but since that time, 
a period of twelve years, he has walked without any artificial support. 
For a year or two he felt a yielding in his ankle, as the weight of his 
body settled upon his limb ; but this gradually ceased, and for some 
years past he has walked without any halt, and seems to step as firmly 
as before the accident. The foot still inclines outwards ;. the tibia 
projects inwards one inch, and the broken ends of the fibula can be 
felt resting against the tibia, where they are reunited. 

Not long since, I had occasion to amputate a limb for a compound 
dislocation inwards, at the ankle joint, and the possibility of this frac- 
ture was confirmed by the dissection. About one-third of the outer 
portion of the articular surface was broken off obliquely, and the frag- 
ment was lying so displaced that a reduction would have been rendered 
impossible. 

Dr. Townsend, of Boston, has reported a case of compound dislo- 
cation, in which also amputation became necessary; and, with other 
injuries, the dissection showed a fragment from the outer margin of 
the tibia, one inch and a half long, and one inch thick at its widest 
part, with a very sharp point, displaced, and lying almost transversely 
over the astragalus. 1 

For a more full account of the prognosis and the general manage- 

1 Townsend, Mass. Hosp. Renprts, Boston Med. and Surg. Journ., vol. xxxiii, 
p. 277. 



DISLOCATIONS OF LOWER EXD OF TIBIA OUTWARDS. 761 



ment of these cases subsequent to the reduction, I beg again to refer 
the reader to the chapter on fractures of the fibula ; and for iny views 
in relation to the treatment of compound dislocations of the ankle- 
joint, I will refer also to the chapter on compound dislocations of the 
long bones. 

\ 2. Dislocations of the Lower End of the Tibia Outwards. 

Syn — " Outward tihio-tarsal luxation;" Malgaigne. " Dislocations of the foot 
inwards," of others. 

The causes are the same or similar to those which are known gen- 
erally to produce dislocations inwards; only that the force of the con- 
cussion or the direction of the rotation must have been reversed. 

The external lateral ligaments, peroneo-tarsal, are either ruptured, 
or the lower portion of the fibula gives way, or both of these circum- 
stances may have happened ; while the internal malleolus may also 
yield to the shock and to the weight of the body now resting upon it. 
The nature of the accident may vary also in respect to the relative 
position of the articular surfaces ; the astragalus may simply rotate on 
its inner and upper margin, or 

the tibia, with the fibula, of FlG - 337 - 

course, may actually slide out- 
wards until the lower end of 
the tibia more or less completely 
abandons the upper surface of 
the astragalus. 

The modes of reduction, and 
the general principles of treat- 
ment subsequently, will not dif- 
fer from those which we have 
mentioned as suitable for dis- 
locations in the opposite direc- 
tion. The examples which have 
fallen under my observation are 
not numerous, but the reduction 
has always been easily effected. 
Thus, a man, set. 21, fell from 
a scaffolding, alighting upon his 
feet. He says that his left foot 
struck the ground obliquely and 
upon its outer margin. I found 
the fibula projecting very strong- 
ly outwards, evidently carrying 
with it the tibia ; the malleolus 
interims was broken off, and the 
foot forcibly turned inwards. 
Without either flexing the leg 
upon the thigh or calling to my 
aid any degree of counter-ex- 
tension except what was made 
by the weight of the body, I grasped the foot and drew upon it gently, 

49 




Dislocation of the lower end of the tibia outwards. 



762 DISLOCATIONS OF LOWER END OF THE TIBIA. 

while at the same moment I rotated the foot outwards. Immediately 
the bones resumed their places. 

In June of 1846, Henry Wilson, set. 38, consulted me in relation to 
his foot, which he said had been dislocated four weeks before. He 
had fallen upon the outside of his foot and turned it suddenly inwards, 
so that when he looked at it he found the sole presenting toward the 
opposite side. Seizing upon it with both hands, he pressed it forcibly 
outwards, and the reduction immediately took place with a snap. 
Very little soreness followed, nor was he confined to his house a single 
day. He had continued to walk about with only a slight halt in his 
gait, nor would he have thought it necessary to consult me at all ex- 
cept that the tenderness had not yet disappeared. He was not aware 
that the fibula had been broken also, until I called his attention to the 
fact. The fracture had taken place two inches above the ankle; and 
although it was already united, the depression occasioned by its having 
fallen in somewhat toward the tibia was very plainly felt and recog- 
nized. 

I 3. Dislocations of the Lower End of the Tibia Forwards. 

Syn. — "Forward tibio-tarsal luxations;" Malgaigne. "Dislocations of the foot 
backwards," of others. 

Causes. — This dislocation may be produced by a violent extension 
of the foot upon the leg ; as, for example, when, the foot being en- 
gaged under a piece of timber, the body falls backwards to the ground; 
or when, the leg remaining fixed, a heavy weight descends upon the 
foot, the foot resting upon an inclined plane; by a blow upon the 
front of the foot ; or it may be caused by a fall upon the bottom or 
back of the tibia, or possibly even by the toes being brought violently 
in contact with some firm body. No doubt it may be caused also by 
any of that class of accidents which are known to produce fractures 
of the fibula with fracture of the malleolus interims, or fracture of the 
fibula with rupture of the internal lateral ligament ; for example, by 
a fall upon the bottom of the foot, or upon the inside of the sole, 
followed immediately by an outward twist of the foot. In these cases 
the luxation of the foot backwards, or, as it is generally found to be, 
the semi-luxation, may be consecutive upon the accident, and the result 
only of the contraction of the gastrocnemii. It may, therefore, occur 
immediately after the fracture has taken place, or not until after the 
lapse of several days. 

Pathological Anatomy. — The displacement may be very slight, so 
that the end of the tibia is only a little advanced upon the astragalus ; 
or it may be such that the tibia rests one-half upon the naviculare 
and one-half upon the astragalus, or it may even desert the astragalus 
entirely. The fibula may at the same time be broken at any point, 
but it is generally broken two or three inches above its lower extrem- 
ity. The malleolus internus is also sometimes broken, but more often 
the internal lateral ligament is torn. Still more rarely a fracture 
occurs through the posterior margin of the articular surface of the 
tibia. 



DISLOCATIONS OF LOWER END OF TIBIA FORWARDS. 763 

Symptoms. — The length of the foot in front of the tibia is dimin- 
ished, while the projection of the heel is correspondingly increased ; 
the toes are turned downwards and the heel drawn upwards, and fixed 
in this position ; the end of the tibia may generally be distinctly felt 
in front of the astragalus; the extensor tendons of the toes are sharply 
defined, while the tendo Achillis is curved forwards, and tense. 

At the regular meeting of the New York Pathological Society, No- 
vember 22, 1865, 1 presented a specimen obtained from the dissecting- 
room of the Bellevue Hospital College. The history of the case was 
unknown. 

Before dissection, the foot was observed to be turned outwards, and 
shortened in front of the tibia, while there was a corresponding length- 
ening of the heel. The specimen, after dissection, disclosed a fracture 
of the internal malleolus half an inch above its lower end, and a frac- 
ture of the fibula a little above its lower end. The tibia was displaced 
forwards about three-quarters of an inch, so that only the posterior 
half of its lower end rested upon the articular surface of the astrag- 
alus, and at the point of contact with the astragalus a new socket was 
formed in the tibia, concave upwards, half an inch deep, and present- 
ing an appearance as if the posterior lip of the lower end of the tibia 
had been broken off and had become displaced upwards. It was sup- 
ported by a broad buttress of bone. It is not certain, however, but 

Fig. 338. Fig. 339. 





Partial dislocation of the tibia forwards, Partial dislocation of the tibia forwards, with frac- 

with fractures of malleolus internus, and ture of the malleolus internus, and fibula, 

fibula. Skeleton. 

that this appearance was occasioned solely by the long-continued pres- 
sure of the tibia upon the astragalus at this point. The fragments of 
the malleolus internus, and the lower fragment of the fibula, remained 
attached to their upper fragments and to the two sides of the astraga- 
lus in their normal positions, consequently each fragment w T as inclined 
downwards and backwards at an angle of 45°. The lower fragment 
of the fibula was driven upwards, also, but both of the fractures were 
firmly united. This specimen is now in the museum of the Bellevue 
Hospital College. 

At the same meeting of the Pathological Society I reported the case 



764 DISLOCATIONS OF LOWER END OF THE TIBIA. 

of Mary Conlan, set. 38, admitted to Bellevue Hospital, November 
13th, 1865, having been thrown three days before from a street ear. 
She could give no account of the manner in which she fell. I saw her 
November 16th. The limb was then much swollen, and I diagnosti- 
cated a fracture of the lower end of the fibula. (It had been supposed 
to be a mere sprain up to this time.) The limb was directed to be wet 
with cool water, and to rest upon a pillow. From this time I looked 
at it occasionally, to see whether the swelling had sufficiently subsided 
to warrant the application of a splint. November 20th it was exam- 
ined again carefully by the house surgeon, Dr. Farrall, but no displace- 
ment was noticed. November 23d I found the lower end of the tibia 
displaced forwards, and ascertained, also, that the internal malleolus 
was broken at its base. The dorsum of the foot, measuring from the 
front of the tibia to the end of the great toe, was shortened half an 
inch. The heel was lengthened. 

There can be no doubt but in this case the dislocation occurred sub- 
sequent to the fracture, and that it was caused by the contraction of 
the gastrocnemii. I reduced the dislocation a day or two later, and 
maintained it in position by the method which I shall presently de- 
scribe. 

Dr. Voss reported to the Society a similar case which had come 
under his notice, and Dr. Buck remarked that he also had met with 
such examples. 1 

Dr. Prince, of Illinois, has reported a case of this character, which, 
remaining displaced, led to a prosecution for damages. A lady, yet. 
40, met with an accident, August 31, 1863, which resulted in a fracture 
of the fibula near its lower end, and a partial dislocation of the tibia 
forwards to the extent of one inch. The toes Avere not pointed down- 
wards, but the foot had its natural angle with the leg. Nearly three 
months after the accident, Dr. Prince, assisted by two other surgeons, 
broke up the adhesions, and reduced the bones to their natural posi- 
tions. 2 

Treatment — The reduction is to be attempted by flexing the leg 
upon the thigh, and making extension from the foot, while, at the 
same moment, pressure is made upon the front of the tibia and against 
the heel. When the bone begins to slide into place, the foot should 
be forcibly flexed upon the leg. A slight lateral motion or rotation in 
either direction may assist in restoring the bones to place. 

In general, the dislocation has been easily reduced, but in a majority 
of the examples recorded great difficulty has been experienced in main- 
taining the reduction ; and in a few cases it has been found impossible 
to do so. 

In order to maintain the reduction, the ]eg, flexed upon the thigh, 
should be laid on its back in a box ; and the foot supported firmly 
against a foot-piece placed at a right angle with the box. In this 
position, the weight of the leg will tend somewhat to overcome the 

1 New York Journ. Med., April, 1866, p. 40. 

2 Cincinnati Journ. Med., April, 1867, p. 202. See also Todd's Cyclopedia of 
Anat. and Phys ; Adams on Ankle-joint, p. 160 et seq. 



DISLOCATIONS OF LOWER END OF TIBIA FORWARDS. 765 

action of the muscles, which are disposed to displace the foot backwards. 
Generally it will be found necessary to make additional pressure directly 
upon the front of the leg above the ankle; which, in order that it may 
not prove mischievous, must be effected with some soft material, and 
must be applied over a broad surface. Perhaps nothing will better 
answer these indications than to pass a cotton band, six or eight inches 
in w r idth, through slits or mortises in the sides of the box ; these slits 
being of a width equal to the width of the band, and placed at a point 
sufficiently below the level of the spine of the tibia, so that when the 
band is made fast underneath the box, it shall press the \eg firmly 
backwards. To prevent the heel from suffering in consequence of this 
pressure, it also should be supported, or suspended by another band 
passing underneath the heel and fastened above to the top of the foot- 
board. The plaster-of- Paris dressing, also, answers the purpose ex- 
ceedingly well in these cases. 

Dupuytren relates the following example of this accident : 

Pierre Froment, set. 33, was carrying a heavy weight upon his back 
and had his right foot in advance, when by accident he came suddenly 
in contact wdth a beam placed across his path. Under the fear of 
being precipitated forwards, he made a sudden effort to throw his body 
backwards, by which he lost his balance, and fell with the point of the 
left foot inclined inwards and forwards, and his whole weight was 
thrown first on the outer side, and then on the front of the ankle-joint. 

On examination, the leg seemed to be planted upon the middle of 
the foot ; the toes were directed downwards and the heel drawn up. 
On the instep there was a large bony prominence, over which the ex- 
tensor tendons of the toes were stretched like tense cords. Behind the 
joint was a deep hollow, at the bottom of which the tendo-Achillis 
could be felt forming a tense, resisting, semicircular cord, with its con- 
cavity directed backwards. The fibula w^as also broken ; the lower end 
of the lower fragment remaining attached to the foot, while the upper 
end of the same fragment was carried forwards by the displacement 
of the tibia, so that it lay nearly horizontally, with its broken ex- 
tremity directed forwards. 

Dupuytren directed one assistant to fix the leg, and a second to 
make extension from the foot, while Dupuytren himself, standing on 
the outer side of the limb, forced the heel forwards and the tibia back- 
wards. The first attempt succeeded partially, and the second completed 
the reduction. The limb was then placed in the apparatus employed 
by this surgeon for a fractured fibula, which we have before described, 
and laid on its outer side in a semiflexed position. The patient re- 
covered rapidly, and in little more than a month he was able to walk. 1 

But such fortunate results have not usually been observed ; indeed, 
Dupuytren encountered much more serious difficulties in two other 
cases which came under his own notice, one of which he has himself 
recorded. This was in the person of a woman set. 48, who was brought 
to the Hotel Dieu in 1815, the accident having just happened from a 
slip in going down stairs. The fibula was broken, and also a frag- 

1 Dupuytren, Injuries and Dis. of Bones, London ed., p. 278. 



766 DISLOCATIONS OF LOWER END OF THE TIBIA. 



ment was broken from the tibia. The house surgeon reduced the 
bones, and placed the limb in the ordinary apparatus for broken legs ; 
but on the following day Dupuytren found them reluxated, and laid 
the limb on his own splint, but the pressure requisite to keep the tibia 
in place soon induced sloughing, ulceration, and abscesses, and after 
four months' treatment, during which time the tibia had been repeat- 
edly displaced, she left the hospital, able to use her limb, but with a 
certain amount of incurable deformity. 1 

Malgaigne mentions the third example as having been seen by him- 
self in Dupuytren's service in 1832, in which case the attempt to main- 
tain the reduction by a tourniquet resulted in gangrene and finally the 
death of the patient. 2 Earle lost a patient after amputation made on 
the eighth day. The tibia could not be kept in place, and the ampu- 
tation became necessary on account of the final protrusion of the bone 
through the integuments, which had sloughed. 3 






% 4. Dislocations of the Lower End of the Tibia Backwards. 

Syn. — "Backward tibio-tarsal luxations;" Malgaigne. "Dislocations of the 
foot forwards," of others. 

More rare than the dislocations forwards, Malgaigne has, neverthe- 
less, succeeded in collecting five examples. 

They appear to have been produced, generally, by a cause the re- 
verse of that which we have seen to produce in certain cases the pre- 
ceding dislocation. Thus, while the dislocation forwards is produced 



Fig. 340. 



Fig. 341. 




Dislocations of the lower end of the tibia backwards 



sometimes when the foot is in violent extension, this dislocation has 
occurred, in at least two or three cases, when the foot was forcibly 
flexed upon the leg. 



1 Op. cit., p. 276. 2 Malgaigne, op. cit., p. 1044. 

3 Malgaigne, op. cit., p. 1044. 



DISLOCATIONS OF UPPER END OF FIBULA FORWARDS. 767 

The symptoms are strongly marked and characteristic. The length 
of the foot from the tibia to the ends of the toes is increased one inch 
or more, the heel being correspondingly shortened, or rather wholly 
obliterated ; a portion of the articulating surface of the astragalus may 
be distinctly felt in front of the tibia ; the posterior surface of the tibia 
touches the tendo-Achillis ; the leg is shortened, and the malleoli ap- 
proach the sole of the foot. 

In most cases one or both of the malleoli have been broken ; and 
R. W. Smith, who has reported one of the examples alluded to, be- 
lieves that the dislocation is never complete. 

Reduction should be attempted by a method similar to that which 
has been recommended in all the other dislocations of the ankle ; only 
with such modifications as the peculiarities of the case must necessarily 
suggest. 



CHAPTER XX. 

DISLOCATIONS OF THE UPPEK END OF THE FIBULA. 

Syn. — " Luxations of the superior peroneo-tibial articulation ;" Malgaigne. 

Surgeons have frequently described a condition of the peroneo- 
tibial articulation in which the ligaments have become relaxed, giving 
a preternatural mobility to the head of the bone. It is also not unfre- 
quently displaced upwards, in consequence of an oblique fracture of 
the tibia. I have myself seen several examples of both these accidents; 
but simple traumatic dislocations, which can only occur forwards or 
backwards, are very rare. 

\ 1, Dislocations of the Upper End of the Fibula Forwards. 

Malgaigne has collected three examples of this luxation, uncompli- 
cated with aiiy other accident, and not, apparently, due to any abnor- 
mal condition of the ligaments, two of which, at least, seemed to have 
been produced by the violent action of the muscles which are attached 
to the anterior face of the fibula. The third example, reported by 
Thompson in the London Lancet? permits a doubt as to whether the 
displacement was occasioned by muscular action, or by a direct blow 
upon the part. 

The signs which characterize the anterior luxation are the absence 
of the head of the fibula in its natural position, and its presence in 
front, near the ligamentum patellae; the altered direction of the biceps 
flexor cruris muscle; and, in one case, considerable deformity in the 
shape and position of the leg has been observed. 

Thompson and Jobard were unable to accomplish the reduction 
while the leg was extended upon the thigh, but succeeded readily after 

1 Op. cit ., 1850, vol. i, p. 385. 



768 DISLOCATIONS OF THE UPPER END OF FIBULA. 

having flexed the leg. On the other hand, Savournin succeeded with 
the leg extended, but with the foot flexed upon the leg. Malgaigne, 
to whom I am indebted for these observations, thinks that flexion of 
the leg, combined with flexion of the foot, would render the reduction 
more easy. 

In whatever position the limb is placed, the surgeon must rely 
chiefly upon forcible pressure made with the fingers against the front 
and upper portion of the displaced bone. 

J. E. Hawley, of Ithaca, N. Y., late Professor of Surgery in the 
Geneva Medical College, has furnished me with a brief account of a 
case which came under his own observation. 

On the 29th of March, 1854, Bambak, while vaulting upon the 
parallel bars in a gymnasium, unintentionally made a complete somer- 
sault, and fell with his right foot upon the edge of a plank. Dr. Hawley, 
who was immediately called, found his right leg semi-flexed and im- 
movably fixed. The head of the fibula was plainly felt in front of its 
natural position, near the ligamentum patella?. The patient was suf- 
fering the most intense pain. Extension and counter-extension were 
made, and while the doctor was pressing with both of his thumbs 
upon the head of the fibula, it went into its place with an audible 
snap. The relief was instantaneous. Complete rest was observed fo 
a few days, while cooling lotions were constantly applied, and withi 
a week he was able to attend to his usual duties. 



le 



I 2. Dislocations of the Upper End of the Fibula Backwards. 

Sanson has recorded one example, in which the passage of the wheel 
of a carriage across the upper part of the leg, precisely on a level with 
the peroneo-tibial articulation, ruptured the ligaments which bind the 
fibula to the tibia, and caused a displacement, which, however, seems 
to have been spontaneously overcome. Nevertheless, there remained 
a preternatural mobility, permitting the fibula to be pushed .easily 
backwards or forwards upon the tibia. 

I have found only two other cases of backward dislocation, one o 
which is related by Dubreuil. A man, set. 62, in order to save him- 
self from falling, sprang suddenly, with his right leg in a position of 
extreme abduction, and at the same moment he experienced a severe 
pain in the region of the peroneo-tibial articulation. The head of the 
fibula was found to be thrown backwards, and formed under the skin 
a marked prominence ; the foot was drawn outwards, and the whole 
outside of the limb became cold and numb. Dubreuil flexed the leg 
moderately, and pressing the head of the fibula from behind forwards, 
the reduction was easily effected. On the following day, the limb 
having been straightened, the dislocation was found to be reproduced. 
It was again replaced, and the knee covered with a leather cap, secured 
moderately tight. After twelve days of complete rest, the knee was 
moved gently, and on the seventeenth day the patient walked with 
the help of a cane. For some time the leg had a tendency to incline 
outwards; but in about three months the cure was perfectly established. 1 

1 Malgaigne, op. cit., torn, ii, p. 386. 



1 



DISLOCATIONS OF THE ASTRAGALUS. 769 

It is probable that in this case the dislocation resulted from the vio- 
lent action of the biceps flexor cruris. Such, at least, is the opinion 
of both Dubreuil and Malgaigne, and I see no reason to question the 
correctness of their theory. 

The other example has been reported by Dr. Jos. G. Richardson, 
resident physician to the Pennsylvania Hospital. John Dixon, set. 9, 
fell five feet and struck upon the outside of the left knee. When ad- 
mitted to the hospital, the leg was partially flexed and the toes a little 
everted, and he was unable to flex or to extend the limb completely. 
The head of the fibula was seen three-quarters of an inch behind its 
natural position, and the biceps was felt distinctly attached. There 
was no other lesion. The reduction was easily accomplished by press- 
ing with the fingers upon the inner and back part of the fibula, 
thrusting it outwards and forwards. A compress and bandage were 
applied, and the limb placed at rest. The reduction continued com- 
plete, and after a few days he was permitted to use the limb. 1 



CHAPTER XXL 

DISLOCATIONS OF THE INFERIOR PERONEO-TIBIAL 
ARTICULATION. 

Nelaton relates the only example of a simple luxation of this ar- 
ticulation of which we have any information. The patient who was 
the subject of this accident presented himself at the hospital under the 
care of M. Gerdy on the thirty-ninth day after the accident, which had 
been occasioned by the passage of the wheel of a carriage obliquely 
across the leg in such a manner as to push the malleolus externus 
directly backwards. The lower end of the fibula was in almost direct 
contact with the outer margin of the tendo-Achillis ; the outer face of 
the astragalus, abandoned by the fibula, could be distinctly felt in 
nearly its whole extent; the foot preserved its natural position; and he 
could walk pretty well, only that he was obliged to step with some care. 
M. Gerdy believed that the bone was too firmly fixed in its new posi- 
tion to be moved, and therefore made no attempt at reduction. 



CHAPTEE XXII. 

tarsal luxations. 

g 1. Dislocations of the Astragalus. 

Malgaigne, who speaks also of luxations " sub-astragaloid," has 
thought proper to call the dislocations which we now T propose to con- 

1 Richardson, Amer. Journ. Med. Sci., April, 1863. 



770 



TARSAL LUXATIONS. 



sider, " double dislocations of the astragalus." In the variety first 
named, the astragalus retains its connections with the tibia, but sepa- 
rates from the scaphoid bone, while its relations to the calcaneum are 
only slightly disturbed. This we prefer to regard as one of the many 
varieties of tarsal luxations, and shall appropriate to it no specific ap- 
pellation, except to designate it as astragal o-scaphoid or astragalo-cal- 
caneo-scaphoid, according as more or less of the several articulations 
are disturbed. 

i In the second named variety, called by Malgaigne a "double" luxa 
tion, and which constitutes the subject of this chapter, the astragalus 
abandons all the articular surfaces against which it is naturally applied, 
and thrusts itself out from between the tibia, fibula, calcaneum, and 
scaphoides; so that it may be said to have suffered a triple or quadruple 
rather than a " double" dislocation, as is implied by the nomenclature 
adopted by Malgaigne. This we choose to regard as the only true dis- 
location of the astragalus, and as such we propose to designate it by the 
simple term "dislocation of the astragalus." 

The astragalus may be dislocated forwards, outwards, inwards, back- 
wards; or it may be dislocated obliquely in either of the diagonals be- 
tween these lines; it may be simply rotated upon its lateral axis, without 
much, if any, lateral displacement; and, finally, it has been occasion- 
ally driven between the 



Fig. 342. 




Dislocation of astragalus outwards. Anatomical relations. 



tibia and fibula, tearing 
away the intermediate 
ligaments, and generally 
fracturing one or both 
bones of the leg. 

Causes. — The causes 
which have been found 
chiefly operative in the 
production of this disloca- 
tion are very much the 
same as those which pro- 
duce, under other circum- 
stances, a dislocation of 
the lower end of the tibia. 
Thus, a fall from a height upon the bottom of the foot, accompanied 
with a violent abduction, adduction, flexion, or extension, may deter- 
mine a dislocation of the astragalus inwards, outwards, backwards, or 
forwards. Sometimes it is accomplished by a mere wrenching and 
twisting of the foot in machinery, or in the wheel of a carriage, or by 
being caught between two irregular bodies. It may be produced also 
by a direct blow. 

Symptoms. — The great prominence occasioned by the displacement 
of the bone in either of these several directions, accompanied generally 
with more or less lateral deviation of the foot, is alone sufficient to in- 
dicate the true nature of the accident. In some cases, also, the foot is 
forcibly flexed or extended ; the leg is shortened in consequence of the 
tibia having fallen down upon the calcaneum; the superincumbent skin 
and tendons are rendered tense; blood is effused, and swelling speedily 



DISLOCATIONS OF THE ASTRAGALUS. 



771 



occurs. In the backward dislocation, the position of the foot is not 
much changed, but the tibia being slightly carried forwards, the length 
of the dorsal aspect of the foot is proportionably diminished. 

Such are the symptoms which plainly enough indicate the disloca- 
tion in the most simple cases ; but in a majority of the examples which 
have been seen, the integuments have been more or less extensively 
torn, exposing to the eye at once the naked bone, and thus removing 
all chance of error in the diagnosis. 

Norris mentions a case, seen by Hammersley, in which the astrag- 
alus was thrown completely out, and was subsequently found in the 



Fig. 343. 



Fig. 344. 





Simple dislocation of the astragalus outwards. 



Compound dislocation of the astragalus inwards. 



earth where the patient had received his injury. Inflammation, gan- 
grene, and tetanus supervened, and the patient died on the seventh 
day. 1 

Prognosis. — It will be readily understood that nothing short of very 
great violence could disturb and completely break up the connections 
of a bone so compactly and firmly seated as is the astragalus, and that, 
aside of any unusual complications, under the most favorable circum- 
stances, intense inflammation must naturally be anticipated; and, with 
few exceptions, this has actually taken place. Even when reduction 
has been promptly and easily effected, inflammation, gangrene, and 
death have sometimes speedily ensued. But more often the reduction 
has been found to be exceedingly difficult or impossible, and complete 
removal of the bone or amputation has been immediately demanded. 

In a limited number of cases, on the other hand, the bone has been 



1 Norris, Amer. Journ. Med. Sci., 1837, p. 



772 TARSAL LUXATIONS. 

easily reduced, and recovery has taken place, with a tolerably useful 
limb; or resection has been practiced with an equally favorable result; 
in still other cases the bone has been left protruding, and the patient 
has finally recovered so far as to be able to walk again, but in such 
a crippled condition as to render the achievement a very doubtful 
triumph of conservative surgery. 

Norris, of Philadelphia, relates the following case, illustrating the 
imminent danger to which even the life of the patient may be exposed 
in those examples which are apparently the most simple. 

William Summerill, set. 30, was admitted to the Pennsylvania Hos- 
pital on the 26th of September, 1831. An hour previous, while de- 
scending a ladder, he slipped and fell in such a manner as to throw 
the entire weight of his body upon the outer part of his left foot. 
The foot was turned inwards, and nearly immovable ; a slight depres- 
sion existed immediately below the lower end of the tibia, and there 
was a hard rounded projection on the outer part of the foot, a little 
below and in front of the extremity of the fibula ; the skin over this 
projection was not broken or excoriated, but reddened ; there was no 
fracture of either bone of the leg. 

The symptoms rendered it plain that the astragalus was dislocated 
forwards and outwards. Dr. Barton, under whose care the patient 
was received, proceeded soon after to make attempts at reduction. 
The muscles of the leg were relaxed as much as possible, and exten- 
sion made from the foot by seizing the heel and front part of the foot 
w T hile an assistant made counter-extension at the knee. The bone was 
also pushed inwards toward the joint by the surgeon. These efforts 
were continued for a considerable time, but had no effect in changing 
the position of the bone. 

Six hours afterwards, Drs. Harris and Hewson being in consultation, 
the attempt was again made to accomplish the reduction, but without 
success ; and the surgeons immediately proceeded to excise the bone. 

An incision was made parallel with the tendons, commencing a short 
distance above the projection, and extending down far enough to ex- 
pose fairly the astragalus and its torn ligaments. The bone was then 
seized with the forceps and easily removed after the division of a few 
ligamentous fibres that continued to connect it with the adjoining parts. 
Very little bleeding occurred, only two small arteries requiring the 
ligature. 

After removal, it was discovered that about one-half of the surface 
which plays in the lower end of the tibia had been fractured, and that 
it remained firmly attached to the extremity of that bone. No attempt 
was made to remove this fragment; but, the joint being carefully 
sponged out, the sides of the w r ound were brought together and closed 
by sutures, adhesive straps, and a roller; after which the foot, placed 
in its natural position, was laid in a fracture-box. 

On the fifth day a slough began to form upon the outside of the foot, 
which was followed by suppuration at other points, and on the thirteenth 
day an opening was made to evacuate the pus near the malleolus in- 
ternus. At the end of about eight weeks the fragment of the astragalus 
which had been suffered to remain was found to be carious, and it was 



DISLOCATIONS OF THE ASTRAGALUS. 773 

removed ; the heel also had ulcerated from pressure, and several other 
bones of the tarsus were discovered to be carious. Fifteen months 
later, this poor fellow was still in the hospital, suffering from hectic, 
with extensive disease in the bones of the tarsus and ankle-joint. 
Finally amputation of the leg was practiced by Dr. Barton, a few days 
after which he died. 1 

Norris mentions also two examples of simple dislocation of the as- 
tragalus at the Pennsylvania Hospital which came under the observa- 
tion of Dr. Barton, in both of which the bone was left unreduced. In 
one case inflammation and sloughing soon effected a complete exposure 
of the protruding bone, but after a time the skin cicatrized. At the 
end of five months the patient walked and had good use of the joint, 
though great deformity of the foot existed, and he continued to be 
subject to ulceration of the newly formed skin on its outer part. In 
the other case gangrene supervened soon after the accident, and the 
patient died. 

Norris adds that "the late Professor Wistar removed the astragalus 
in a case of compound dislocation, and the patient was cured with some 
motion at the joint." 

Dr. Alexander Stevens, of New York, made the same operation in 
a case of compound dislocation, and, after several months, he affirms 
that the patient " has recovered with very trifling deformity of the foot, 
and with a flexible joint. He walks with very slight lameness." 2 

I am indebted to Dr. B. H. Hart, of Marietta, Ohio, for an account 
of the following case, and for the specimen, which has, also, kindly 
been put in my possession. 

In June, 1853, Thomas Williams was thrown from his carriage, 
alighting upon his left foot and causing a compound dislocation of the 
ankle-joint. Dr. Hart was immediately called, and found the bones 
of the leg thrust through the integuments on the outside, the malleolus 
interims broken, and the astragalus partially dislocated. After enlarg- 
ing the opening in the integuments with a pocket-knife, the doctor was 
able to reduce the dislocated bones to place. It must be mentioned 
that this man weighed 225 lbs., and that in his fall he descended a 
precipice or bank 30 feet in height. Soon after the reduction the 
patient had two severe convulsions, which were arrested by bleeding 
and opiates, and never returned. Cool lotions were applied to the 
limb ; and on the sixth day erysipelas supervened and extended nearly 
to the body. The erysipelas continued about nine days. Extensive 
suppuration throughout the joint resulted, and some fragments of bone 
came away, and on the thirty-third day Dr. Hart removed, without 
the aid of the knife, the entire astragalus. In three months the patient 
walked upon crutches, and in eleven months he could walk w^ell with- 
out a staff, a slight motion having been preserved in the ankle-joint. 

The dislocations backwards, of which I have found recorded only 
eight examples, have all, with but one exception, been left unreduced; 
yet in at least five instances the patients have recovered with pretty 

1 Norris, Araer. Journ. Med. Sci., Aug. 1837, p. 378. 

2 Stevens, North Amer. Med. and Surg. Journ., Jan. 1827, p. 200:. 



774 TARSAL LUXATIONS. 

useful limbs. Such was the fact with Liston's, Lizar's, and my own 
patients, and also with Mr. Phillips's two cases, to all of which I shall 
again refer. It must be noticed, however, that in each of the cases 
mentioned as followed by a successful termination without reduction, 
the dislocations were simple. 

Turner, of Manchester, has reported one example of compound lux- 
ation outwards and backwards, in which, finding himself unable to 
effect reduction, he removed the astragalus, with a tolerably successful 
result. 1 Finally, a case was presented in one of the London hospitals 
in 1839, of a dislocation inwards and backwards, which was reduced 
in about ten minutes, by extension accompanied with lateral pressure. 2 

In Sept. 1870, I saw, with Dr. Sayre, in consultation, a dislocation 
of the astragalus forwards and outwards, in the person of Mr. Stewart, 
of this city, which had just occurred in consequence of an injury re- 
ceived in being thrown from a carriage. The dislocation seemed to be 
nearly complete, causing great projection and tension of the skin. 
Under the influence of chloroform, by extension and pressure, it was 
easily reduced by Dr. Sayre. In five weeks from this time he was able 
to walk, and soon after the restoration of the functions of the joint was 
complete. 

Treatment — Various attempts have been made by surgical writers 
to determine the line of treatment which should be adopted in these 
unfortunate cases, but with very unsatisfactory results, since they are 
far from having arrived at similar conclusions, nor have they been able 
always to settle the question definitely for themselves. The difficulty 
consists in the multiplicity and lack of uniformity in the complications 
which attend these accidents, rendering it impossible to establish a 
classification upon which a uniform treatment may be safely based. 
There are certain principles, however, which seem to be sufficiently 
settled to allow of an authoritative announcement; these may be briefly 
stated as follows : If the dislocation is simple, reduce the astragalus 
immediately, provided this is possible. If the luxation is complete, 
and it cannot be reduced, even partially, proceed at once to resection 
or to amputation. In compound dislocations, resection or amputation 
affords the only safe resource. In all cases the inflammation is likely 
to be intense, in order to prevent which complication the surgeon must 
be unremitting in his use of the appropriate remedies. 

Out of eighteen cases of«complete excision of the astragalus, collected 
by Turner, fourteen made good recoveries, and in only one of these 
fourteen was there anchylosis. 

The several indications and rules of treatment above enumerated we 
shall proceed to illustrate a little more fully. 

In a recent simple luxation of the astragalus forwards, the leg should 
be flexed to a right angle w r ith the thigh, and, for the purpose of mak- 
ing extension, one assistant should take hold of the foot with both 
hands in the same manner that a servant draws a boot, that is, with 

1 Turner, Trans. Provin. Med. and Surg. Journ., vol. ix. Essay on Disloc. of 
Astrag., with nearly fifty cases. For additional cases, see Med. and Surg. Reporter, 
Jan. 1867. 

s London Lancet, vol. ii, p. 559. 



DISLOCATIONS OF THE ASTRAGALUS. 775 

the right hand grasping the heel, and the left placed upon the dorsum 
of the foot, near the toes. A second assistant should seize the lower 
part of the thigh, in order to make counter-extension, while the sur- 
geon presses with the ball of his hand against the head of the astragalus, 
upwards and backwards. If these simple measures fail, the pulleys 
ought to be employed as a substitute for the hands in making exten- 
sion. In applying the extension, the toes must be kept well down, 
and occasionally the foot should be moved gently from one side to the 
other. 

An oblique dislocation must be reduced, if possible, to an anterior 
luxation, before an attempt is made to carry the head of the bone back 
to its place, as by this mode the reduction will be greatly facilitated. 

Lateral luxations may be reduced by the same means ; but if the 
astragalus is dislocated outwards, the foot must be held forcibly ad- 
ducted during the extension ; and if it is dislocated inwards, the foot 
must be held strongly in the opposite direction. 

Lizars says that he has seen one case of backward luxation, and 
that all attempts at reduction were unavailing. The limb was, how- 
ever, preserved, and proved to be useful. 1 Liston was equally unsuc- 
cessful in a case which came under his notice. 2 Phillips has reported 
two cases, in neither of which was the reduction accomplished. 3 Nel- 
aton has seen a compound dislocation which he could not reduce. 4 
Mr. Erichsen, however, who admits that when dislocated backwards it 
has not hitherto been reduced, declares that the surgeons at University 
Hospital have succeeded in one case recently, in which both the tibia 
and fibula were broken also. 5 Mr. Erichsen suggests also that, in case 
of a failure by the ordinary means, we should resort to a subcutaneous 
section of the tendo-Achillis. Mr. Williams, of Dublin, in a similar 
case, which had been left unreduced, was obliged finally to extract the 
bone, in consequence of the integuments having sloughed. 6 

In February, 1875, Mr. J. N. Hall, of Colorado, set. 38, consulted 
me in reference to an injury of his foot sustained two years before. 
The foot had been caught between a couple of timbers and violently 
twisted inwards. The nature of the accident was not at first recognized. 
I found the astragalus displaced backwards as far as the posterior ex- 
tremity of the calcaneum, causing the tendo-Achillis to curve back- 
wards; the astragalus was especially prominent on the inner side, 
posteriorly. The foot was at a right angle with the leg, and shortened 
in front three-eighths of an inch. The leg was shortened five-eighths 
of an inch. The foot was at times painful and numb. He walked 
very well with the aid of a cane. Of course, no surgical interference 
could be recommended. 

Compound dislocations, and such as are otherwise complicated, de- 
mand of the surgeon immediate amputation or exsection, the latter 

1 Lizxrs, System of Practical Surg., Edinburgh ed., 1847, p. 161. 

2 Liston, Elements of Surgery, vol. iii, p. 348. 

3 Phillips, Lond. Med. Gaz., vol. xiv, p. 596. 

4 NSlafcon, Pathologie Chirurg., t. ii, p. 482. 

5 Erichsen, Science and Art. of Surg., Amer. ed., 1859, p. 270. 

6 Williams, Erichsen, op. cit., p. 271. 



776 



TARSAL LUXATIONS. 



of which ought to be preferred whenever the condition of the limb 
encourages a reasonable hope that the foot may be saved. 

Dr. Grant, of Canada, has reported a case, however, of success after 
reduction of a compound dislocation of this bone. The man was 35 
years old, and in good health. Immediately after the accident the 
astragalus was found completely dislocated forwards, and lying with 
its long axis placed transversely, so that the anterior extremity pro- 
truded through the integuments one inch on the outer side of the foot. 
There was no fracture. The first attempt at reduction, by extension 
and pressure, failed ; but in the second attempt moderate pressure, 
without extension, was successful. Suppuration ensued, and continued 
two months. At the end of eight months he walked without a cane; 
and at the date of the report the ankle was in all respects perfect. 1 

When exsection is practiced, and the bone is found to be broken, as 
it often is, all the fragments should be carefully removed, since they 
are certain to become necrosed if left in place. Nor ought the surgeon 
to hesitate to lay open freely the tissues in every direction, in order 
that he may accomplish this purpose ; even the tendons lying over the 
protruding bone may be sacrificed unhesitatingly, since, after having 
been so severely bruised, stretched, and lacerated, they are pretty cer 
tain to slough. Indeed, the more freely the tissues are divided over 
the bone, the less will be the danger of inflammation, and the safer will 
be the life and limb of the patient. 

In addition to the examples already cited of compound dislocation 
in which the astragalus was removed, the following, reported by Dr. 
W. A. Gillespie, of Ellisville, Va., will also illustrate the occasional 
value of exsection in these severe accidents. 

Mrs. A., aged about 50 years, fell from a horse on the 23d of May, 
1833, dislocating both ankles. The luxation of the right foot was 
accompanied with a luxation of the astragalus outwards, which pro- 
jected through a very large wound in the integuments, and its trochlea 
was placed at an angle of about 45° with its natural position. Early 
on the following day it was removed by severing its few remaining 
connections, and the wound was immediately closed by stitches, ad- 
hesive plasters, and light dressings. From the moment of the receipt 
of the injury, and for several days afterwards, she suifered excruciating 
pain in the limb, and on the third day tetanus was apprehended, but 
its full accession was prevented by the free use of opiates. The limb 
was suspended in N. R. Smith's fracture-apparatus ; and as gangrene 
with hectic fever soon threatened the life of the patient, fermenting 
poultices were diligently applied, and the patient was sustained by wine, 
bark, and other tonics. Two months after the injury was received, 
the date at which the report is given, the wound had entirely healed, 
and her complete recovery was regarded as certain. 2 Many other 
similar examples have been reported by foreign surgeons. 

One word more with regard to the treatment of the wound after 
excision. A considerable experience in .accidents and .wounds of this 



1 Grant, Canada Med. Journ., Oct. 1865. 

2 Gillespie, Amer. Journ. Med. Sei., Aug. 1833, p. 552. 



ASTRAGALO-CALCANEO-SCAPHOID DISLOCATIONS. 777 

class, that is, wounds accompanied with great contusion and laceration, 
has convinced me that the practice of closing the surface with sutures, 
adhesive plasters, bandages, etc., is eminently pernicious. The effusions 
which must naturally occur, and which indeed we think ought to occur, 
are thus imprisoned beneath the skin, giving rise to swelling, pain, 
inflammation, and finally suppuration or sloughing. It is far better, 
in our opinion, to leave the wound open, covering it 'only with cloths 
constantly kept moist with cool water. For this latter purpose some 
mode of irrigation is preferable, as being more constant and uniform. 
To those who have never adopted this treatment of contused wounds, 
or of wounds generally, we would recommend an early trial, feeling 
confident that they will never have occasion to regret the experiment. 

I 2. Astragalo-Calcaneo-Scaphoid Dislocations. 

It is perhaps quite as common for the astragalus to be dislocated 
from the scaphoid bone and calcaneum, while it retains its connections 
with the tibia, as to be luxated from all these bones at the same time. 
This astragalo-calcaneo-scaphoid dislocation is that which Malgaigne 
has termed " subastragaloid." Produced by the same causes which 
determine true dislocations of the astragalus, it may occur in the same 
directions, and is liable to the same complications; nor will either the 
prognosis or treatment differ essentially from that which is recognized 
and established in the other accident. 

As in dislocations proper of the astragalus, so also in this accident, 
opposite results have occasionally followed from similar modes of treat- 
ment. Thus, Dr. Detmold, of Xew York, stated in 1856 to the Xew 
York Academy of Medicine, that he had recently met with a disloca- 
tion of the astragalus, in which the bone retained its proper relations 
with the tibia, but not with the bones of the tarsus. The patient had 
fallen from a wagon and caught his foot in the wheel. Dr. Detmold 
made extension with pulleys, but could not effect the reduction. Sub- 
sequently he was obliged to remove the astragalus on account of the 
suppuration which followed and the consequent exposure of the bone. 
The wound did not heal kindly, and at length amputation of the leg 
became necessary. 

Dr. Detmold concludes, from this example and others which have 
come to his knowledge, that if a similar case were to present itself to 
him again, he would amputate at once. 1 

The following case, reported by Dr. Thomas Wells, of Columbia, 
S. C, is of unusual interest, as illustrating the danger of leaving the 
bone displaced, and also the benefit which may, even under the most 
unfavorable circumstances, result from its final removal. 

Dr. S., set. 30, was riding in an open carriage, some time during the 
year 1819, when his horses became frightened and ran, and in leaping 
from his vehicle he struck upon his left foot, dislocating the astragalus 
from its junction with the scaphoid bone, upwards and slightly out- 
wards. Several medical gentlemen made violent efforts to reduce the 

1 Detmold, New York Journ. Med., May, 1856, p. 383. 
50 



778 TARSAL LUXATIONS. 

bone, but without effect. Inflammation and suppuration, accompanied 
by a high fever, soon followed, and the head of the astragalus becom- 
ing carious, protruded through the skin. On the 18th of August, 
about seven months after the injury was received, he was still suffering 
from a copious discharge, pain, swelling, and general irritative fever, 
and it was determined to excise the bone ; which was accordingly done 
by enlarging the wound and detaching its loose connections with the 
adjacent tissues. The astragalus extracted left a frightful wound, the 
foot seeming to be nearly separated from the leg. A hollow splint was 
adjusted to the inside of the foot and leg, so as to preserve the limb 
perfectly steady and in a proper direction ; simple dressings were ap- 
plied, and an anodyne administered internally. No accidents followed, 
and at the end of September the wound was healed, and the swelling 
of the parts had entirely subsided. One year after the operation, he 
walked without the least difficulty; the ankle being then " perfectly 
sound." The leg was shortened about one inch, and this deficiency 
was supplied by a thick heel upon his shoe. 1 

Examples might be cited illustrative of the value of early exsection 
where reduction could not be accomplished ; but, after what has already 
been said upon the subject of dislocations of the astragalus, we shall 
not regard any farther reference as either necessary or useful. If other 
principles of treatment are to govern the surgeon than those which we 
have already laid down, they cannot here be stated. They are among 
those unwritten rules whose existence we cannot always recognize until 
the case arises upon which they may apply. Yet, in the exigency 
supposed, they are as clearly defined, and as imperative, in the mind 
of the clever surgeon, as any of those laws which have been made the 
subjects of special record. 

\ 3. Dislocations of the Calcaneum. 

The calcaneum may, as a consequence of a fall upon the heel, or of 
a direct blow, be dislocated outwards from the astragalus alone, or up- 
wards and outwards from the cuboid bone at the same time. It has 
been found also at the same moment dislocated outwards from the 
astragalus and inwards upon the cuboid bone. 

Chelius says he has seen an old dislocation of the calcaneum, pro- 
duced in early life by pulling off a boot, from which there finally 
resulted a degeneration like elephantiasis of the leg, rendering ampu- 
tation necessary. 2 

Mr. South remarks, in his Notes to Chelius, that the two cases of 
dislocation outwards of this bone, mentioned by Sir Astley Cooper, 
w T ere from his (South's) Notes (cases 199 and 200). In the first case, 
that of Martin Bentley, occasioned by the falling of a heavy stone 
upon his foot, the integuments were not broken, and the position of 
the foot resembled a varus. " The dislocation was easily reduced, 
having bent the thigh and knee on the body and fixed the leg, by 

1 Wells, Amer. Journ. Med. Sci., May, 1832, p 21. 

2 Chelius, System of Surg., Amer. ed., vol. ii, p. 354. 



DISLOCATIONS OF THE OS CUBOIDES. 779 

laying hold of the metatarsus and of the tuberosity of the heel-bone, 
and drawing the foot gently and directly from the leg, during which 
extension Cline put his knee against the outside of the joint, and the 
foot being pressed against it, the heel and the navicular bone readily 
slipped into their place, and the deformity disappeared." He was dis- 
charged from the hospital in five weeks, "having the complete use of 
his foot." 

In the second case, the dislocation, produced also by the fall of a 
stone upon the foot, was compound, and the patient, Thomas Gilmore, 
having been brought into St. Thomas's Hospital, the reduction was 
effected by extending the foot and rotating it outwards. Six months 
after, when he left the hospital, he was able to walk pretty well with 
a stick. 

I 4. Middle Tarsal Dislocations. 

The scaphoid and cuboid bones may be dislocated from the astrag- 
alus and calcaneum, constituting what is termed, by Malgaigne, a 
middle tarsal dislocation. It is probable that, to some extent, the same 
thing has occurred in many of those cases which are reported as simple 
dislocations of the astragalus, or as dislocations at the astragalo-scaph- 
oid articulation; but it occurs also occasionally in a degree so perfect 
and complete as to leave no doubt as to the true nature of the disjunc- 
tion, and to entitle it to a separate consideration. 

Mr. Liston mentions the case of a boy, set. 14, who fell from a height 
of forty feet, striking, apparently, upon the extremity of the foot. The 
scaphoid and cuboid bones were found to be displaced upwards and 
forwards, so that the foot was shortened about half an inch, and had a 
clubbed appearance. No attempt was made to reduce the bones, and 
he left the hospital in three weeks, able to stand on the foot. 1 Sir 
Astley Cooper has recorded in more detail a similar example. A man, 
working at the South wark bridge, London, received upon the top of 
his foot a stone of great weight. He was immediately carried to Guy's 
Hospital, and his condition is described as follows : " The os calcis and 
the astragalus remained in their natural situations, but the forepart of 
the foot was turned inwards upon the bones. When examined by the 
students, the appearance was so precisely like that of a club-foot, that 
they could not at first believe but that it was a natural defect of that 
kind;" but, upon the assurance of the man that previously to the acci- 
dent his foot was not distorted, extension was made, and the reduction 
was effected. He was discharged from the hospital in five weeks, 
having the complete use of his foot. 2 

I 5. Dislocations of the Os Cuboides. 

According to Piedagnel, quoted by Chelius, the cuboid bone may 
be dislocated upwards, inwards, and downwards, but Malgaigne affirms 
that he has found no case recorded in which the dislocation has oc- 



1 Practical Surgery; also London Lancet, vol. xxxv'ii, p. 133. 

2 Sir A. Cooper on Disloc, etc., London ed., 1823, p. 376. 



780 TARSAL LUXATIONS. 

curred alone, or unaccompanied with a dislocation of one or more of 
the other tarsal bones. 

I 6. Dislocations of the 0s Scaphoides. 

Burnett has seen a luxation of the scaphoid bone in which its con- 
nections with the astragalus were undisturbed, while at the same time 
it was completely separated from the cuneiform bones. By strong 
pressure exercised during several minutes, the os scaphoides was made 
to fall into its place. The dislocation was compound, yet the wound 
healed rapidly, and in a short time the recovery was almost complete. 1 

Several examples are recorded of a true luxation of the os scaphoides, 
in which the bone had abandoned both the astragalus on the one hand, 
and the cuneiform bones on the other. 

Piedagnel mentions a case in which the scaphoid bone was broken 
longitudinally, and its internal fragment, constituting the largest por- 
tion, was displaced inwards through a tegumentary wound. He was 
unable to effect reduction, and was compelled to amputate the foot. 2 

Walker has reported the first example of luxation forwards, occa- 
sioned by jumping upon the ball of the foot. The bone formed a 
marked projection upon the top of the foot, and a corresponding de- 
pression existed below. An attempt was first made to accomplish the 
reduction by simple pressure with the thumbs; but this having failed, 
the surgeon bent the extremity of the foot forcibly downwards, and by 
continuing to press upon the os scaphoides, it fell into its position 
easily and with a distinct click. In about three weeks the patient was 
able to walk with only a slight halt, and no deformity remained. 3 

2 7. Dislocations of the Cuneiform Bones. 

The cuneiform bones may be luxated partially, and without having 
separated from each other, of which two or three examples are recorded ; 
or, which is more common, the cuneiforme internum may be luxated 
alone. Says Sir Astley Cooper : " I have twice seen this bone dislo- 
cated; once in a gentleman who called upon me some weeks after the 
accident, and a second time in a case which occurred in Guy's Hospital 
very lately. In both instances the same appearances presented them- 
selves. There was a great projection of the bone inwards, and some 
degree of elevation, from its being drawn up by the action of the tibia- 
lis anticus muscle; and it no longer remained in a direct line with the 
metatarsal bone of the great toe. In neither case was the bone reduced ; 
the subject of the first of these accidents walked w T ith but little halting, 
and I believe would in time recover the use of the foot, so as not to 
appear lame. The cause of the accident was a fall from a considerable 
height, by which the ligament was ruptured which connects this bone 
with the os cuneiforme, and with the os naviculare. The second case, 
which was in Guy's Hospital, my apprentice, Mr. Babington, informs 

1 Burnett, Lond. Med. Gazette, 1837, vol. xix, p. 221. 

2 Pieclagnel, Journ. Univ. et Heb., torn, ii, p. 208. 

3 Walker, The Medical Examiner, 1851, p 203. 



DISLOCATIONS OF THE CUNEIFORM BONES. 781 

me, happened by the fall of a horse, and the foot was caught between 
the horse and the curbstone." 1 

In a case of compound luxation seen by Mr. Key, reduction was 
effected, and in two months the cure was so far completed that the 
patient walked with only a slight lameness. 2 Nelaton, in a similar 
case of compound luxation, unable to reduce the bone, removed it com- 
pletely, and the patient recovered. 3 

Robert Smith has called attention to a species of dislocation of the 
internal cuneiform bone not before very accurately described ; but of 
which he has presented two examples. It consists in simultaneous 
dislocation of the metatarsus and internal cuneiform ; that is to say, the 
first metatarsal bone, together with the internal cuneiform, is dislocated 
upwards and backwards upon the tarsus, carrying with it also the four 
remaining metatarsal bones. In both of the examples seen and re- 
corded by him, the dislocations were ancient, and no account could be 
obtained of the precise manner in which the accidents had been pro- 
duced. The feet were foreshortened to the extent of an inch or more, 
in consequence of the overlapping of the bones, yet the heel in each 
case preserved its natural relations to the tibia, not being proportion- 
ately lengthened as is the case in dislocations of the tibia forwards. 
The plantar surface of the foot was turned inwards, and instead of 
being concave it was convex, both in its antero-posterior and transverse 
diameters. A transverse ridge on the top of the foot also indicated 
the line of the projecting bones. Both of these cases were verified by 
a careful dissection. 4 

Dupuytren has reported in his Treatise on Injuries of the Bones, a 
similar case, occurring in a woman, set. 30, who was brought immedi- 
ately to Hotel Dieu. She stated that in descending from the bridge 
of St. Michael, with a burden of two hundred pounds, she fell in such 
a way that the whole weight of the body was received on the right 
foot, and that, at the moment she made an effort to check herself in 
falling, she experienced extremely severe pain in this part, and heard 
a very distinct snap; she was unable to raise herself from the ground. 
On the following morning Dupuytren reduced the bones with very 
little difficulty by extension, combined with pressure against the dislo- 
cated ends. The bones went into place with a loud snap, and in two 
or three months she left the hospital, with only a little lameness. 5 

Mr. Smith, without intending to question the possibility of a simple 
luxation of the metatarsal bones, of which, indeed, Malgaigne has 
collected a number of well-authenticated examples, is inclined to be- 
lieve that, when a luxation of the bones of the metatarsus is the con- 
sequence of a fall from a height, the individual alighting upon the 
anterior part of the foot, it is, in general, that variety which has now 
been described. And this aptness on the part of the cuneiform bone 

1 Sir Astley Cooper, op. cit., p. 388. 

2 Key, Guy's Hosp. Rep., 1836, vol. i, p. 544. 

3 Nelaton, Malgaigne, op. cit., p. 1076. 

4 Robert Smith, Treatise on Fractures, etc., Dublin ed., 1854, p. 224 et seq. 

5 Dupuytren, op. cit., p. 326. 



782 DISLOCATIONS OF THE METATARSAL BONES. 

to maintain its connection with the first metatarsal bone, he would 
ascribe mainly to the fact that both the peroneus longns and tibialis 
anticns have attachments to each of the bones in question. 



CHAPTER XXIII. 

DISLOCATIONS OF THE METATAKSAL BONES. 

Luxations of one or more of the metatarsal bones, at the points of 
their articulations with the tarsus, have been known to occur in almost 
every direction. They may be occasioned by crushing accidents, by 
machinery, or more often perhaps they have been caused by a fall 
backwards or forwards when the anterior extremity of the foot was 
wedged under some solid body and immovably fixed. They may be 
produced also, probably, by simply striking upon the ball of the foot 
in falling from a height. We have noticed, however, that Mr. Smith 
inclines to the opinion that this will, in general, only produce the spe- 
cies of dislocation which he has particularly described. 

The symptoms which characterize the dislocation of the whole range 
of metatarsal bones upwards and backwards will, when the dislocation 
is complete, resemble very much those which belong to the dislocation 
described by Smith. The dorsum of the foot will be shortened antero- 
posteriorly, the two arches of the foot will be lost upon the plantar 
surface, or even actually reversed, a ridge will traverse the back of the 
foot and a corresponding depression will exist underneath. 

In some cases, however, the dislocation is not complete, the articu- 
lations being only sprung, and then there can exist no foreshortening 
of the foot, and all the other signs will be less striking. 

If only a single bone is luxated the diagnosis is generally very 
easily made out, unless indeed considerable swelling has already oc- 
curred. 

Mr. South says that, in 1835, a case was admitted to St. Thomas's 
Hospital, under Mr. Green's care, of dislocation of the last two meta- 
tarsal bones, occasioned by the falling of a heavy chest upon the inside 
of the foot. Upon the top of the foot was a large swelling below and 
in front of the outer ankle, and behind it a cavity in which two fingers 
could be easily buried, in consequence of the bases of the metatarsal 
bones having been thrown upwards and backwards upon the top of 
the cuboid bone. The reduction was accomplished with much diffi- 
culty by continued extension, and as the bones resumed their place a 
distinct crackling was heard. 1 

Liston reduced a dislocation upwards of the first metatarsal bone ; 
Malgaigne mistook a dislocation of the fourth bone for a fracture, and 

1 South, Note to Chelius's Surg., vol. ii, p. 256. 



DISLOCATIONS OF THE METATARSAL BONES. 783 

did not attempt the reduction until the seventh day, when, after five 
successive trials, the head entered with a noise into its cavity. In a 
dislocation of the second, third, and fourth metatarsal bones, he also 
failed to detect the true nature of the accident until the tenth day, 
when he proceeded to attempt reduction, but failed. Inflammation, 
suppuration, and delirium followed, and the patient died on the forty- 
first day. Tufnell failed in a similar case, although his patient finally 
recovered with a not very useful limb. Malgaigne failed to reduce 
the bones also in a recent case of luxation of the first four bones, al- 
though he used chloroform and diligently tried various means. The 
same writer has seen one example of ancient dislocation, which was 
not recognized by the surgeon. Finally, Monteggia reports a case of 
dislocation of the last two metatarsal bones, which was not at the time 
recognized. On the tenth day swelling commenced, and soon after the 
patient died in convulsions. 1 

These references, drawn chiefly from Malgaigne, sufficiently illus- 
trate the difficulty which surgeons have experienced in the reduction 
of these bones, when a portion only is displaced. A difficulty which 
is probably due to the fact that it is almost impossible to make ex- 
tension upon a single metatarsal bone ; indeed, it is probable that by 
pressure only upon the displaced head can we expect to accomplish 
much in these accidents, and even this cannot be made to act very 
effectively, owing to the small amount of surface presented against 
which the force can be properly applied. 

If, on the other hand, all the bones are dislocated at once, the re- 
duction is generally accomplished with ease by simple extension, com- 
bined with properly directed pressure. Bouchard and Meynier suc- 
ceeded without difficulty in. two cases of backward dislocation; Smyly 
was equally successful on the sixth day, in a case of dislocation down- 
wards. Laugier reduced an outward dislocation of all the bones by 
pressure and extension easily ; and Kirk succeeded as well, in an ex- 
ample of the opposite character, all the bones being carried inwards. 2 

Mr. Sandw T ith has given us an account of a case which occurred in 
his own person, from the fall of his horse upon his foot. " I was in- 
stantly sensible/' says Mr. Sandwith, "of the nature of the injury, 
and as soon as I was upon my feet, the metatarsus was found to be 
drawn upwards, and obliquely outwards upon the tarsus, by the action 
of the flexor muscles. On the removal of the boot, which w 7 as cut 
away, these were the appearances : The foot considerably shortened, 
the toes turned a little outwards, and a hard swelling, bigger than an 
egg, upon the tarsus, with tumefaction of the integuments. The pain, 
which was great at first, was kept under by a warm fomentation. 

" The reduction was easily effected by my friends Messrs. Williams 
and Brereton, and leeches and bread-and-water poultices prevented 
inflammation. For several nights the foot was violently shaken by 
spasmodic action of the muscles, but the parts preserved their relative 
situation ; and, although it w r as nearly a year before all lameness 
ceased, yet at the end of six weeks I was enabled to lay aside my 

1 Malgaigne, op. cit., p. 1077 et seq. 2 Ibid., op. cit., p. 1081. 



784 DISLOCATIONS OF THE PHALANGES OF THE TOES. 

crutches. For the ability to use the foot in so short a time, I was 
indebted to a contrivance which rendered the foot and ankle inflexible. 

" Instead of an elastic sole to the shoe part of the apparatus, one of 
wood was procured, around the heel of which was nailed a piece of 
firm, unbending leather; this reached as high as the calf of the leg; 
three small straps with buckles held the leg in situ, and a broader one 
across the instep secured the foot. The comfort I experienced from 
this simple apparatus is my reason for describing it so particularly; it 
has since been found useful in various injuries of the foot and ankle." 1 

In one extraordinary case, however, Dupuytren was not so success- 
ful. Paul Eudes, set. 24, fell, while drunk, into a ditch six feet deep, 
and alighted on the soles of his feet. The accident was followed by 
great swelling, and he did not suspect the nature of the injury, nor 
present himself at the hospital until three weeks after. Dupuytren 
then ascertained that he had dislocated the metatarsal bones of both 
feet. Several fruitless attempts were made to accomplish the reduc- 
tion, but to no purpose, and in about two weeks he left the hospital. 2 



CHAPTER XXIV. 

DISLOCATIONS OF THE PHALANGES OF THE TOES. 

Dislocations of the toes are less common than those of the fingers, 
yet a considerable number of cases have been recorded by different 
surgeons. They are occasioned by blows received directly upon the 
ends of the toes ; by the weight of the body brought to bear suddenly 
upon their plantar surfaces, as when a horseman springs in his stirrup, 
or by a fall, in consequence of which the rider hangs 'in his stirrup; 
by leaping, etc. 

They may be partial or complete ; and in the latter case, a slight 
overlapping is generally observed. In a great majority of cases the 
direction of the displacement is backwards, or with only a slight lateral 
deviation. Occasionally several bones are displaced at the same time, 
but usually only one suffers displacement. It is more common here 
to find compound and complicated dislocations than in the case of the 
fingers. 

The position of the toes is not always the same in the same form of 
dislocations. Thus, in the dislocation backwards, the toe is sometimes 
reversed upon the foot to nearly a right angle, and at other times it is 
found lying in the same axis as the metatarsal bone, or the phalanx, 
from which it is luxated. About one year since, I reduced a backward 
dislocation of the first phalanx of the second toe in the person of Lewis 
Britton, set. 60, who had fallen from a fourth-story window, striking 

1 Sandwith, Amer. Journ. Med. Sci., Nov. 1828, p. 216; from Lond. Med. Gaz., 
vol. i. 

2 Dupuytren, op. cit, p 329. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 785 

upon his feet, and breaking both thighs. I did not discover the dislo- 
cation of the toe until sixteen hours after the accident. It was then 
lying parallel with the axis of the metatarsal bone, upon which it was 
slightly overlapped. The reduction was effected easily by pulling upon 
the last phalanx with my fingers, while at the same moment I pushed 
the head of the bone toward the socket. No swelling followed, nor 
has it troubled him at all since his recovery. 

With regard to the treatment, surgeons have experienced the same 
difficulty in certain cases of dislocation of the great toe as we have 
seen experienced in similar dislocations of the thumb. Occasionally, 
indeed, the reduction has been found to be impossible. The same 
doubts have existed also in relation to the causes of this difficulty, and 
in reference to the means by which it was to be overcome. We shall 
therefore refer the reader to the chapter on Dislocations of the First 
Phalanges of the Thumb and Fingers, for a more full consideration of 
this matter. 

In case the smaller toes are luxated, the reduction is generally 
effected with ease, by simple extension, or by extension combined with 
pressure ; sometimes, also, the bone will be more easily put in place by 
reversing the phalanx more completely, as we have advised in certain 
cases of dislocation of the fingers. 

If the skin is penetrated, it will often be found necessary either to 
amputate or to practice resection upon the exposed phalanx. 

Sir Astley Cooper relates a case of luxation of " all the smaller 
toes," from the metatarsus, which had not been reduced, and the sub- 
ject of which was, in consequence, so much maimed that he was unable 
to labor. It had been occasioned by a fall, from a considerable height, 
upon the extremities of the toes. A projection existed at the roots of 
all the smaller toes, the extremity of each metatarsal bone being placed 
under the first phalanx of its corresponding toe. The swelling which 
immediately followed the receipt of the injury, had concealed its nature, 
and now, several months having elapsed, reduction could not be effected. 
The only relief which could be afforded him, therefore, was in wearing 
a piece of hollow cork at the bottom of the inner part of the shoe, to 
prevent the pressure of the metatarsal bones upon the nerves and 
bloodvessels. 1 



CHAPTER XXV. 

COMPOUND DISLOCATIONS OF THE LONG BONES. 

Frequency of Compound as compared with Simple Dislocations. — Com- 
pound dislocations, as compared w r ith simple > are of rare occurrence. 
Of ninety-four dislocations reported by Xorris as having been received 
into the Pennsylvania Hospital for the ten years ending in 1840, only 

1 Sir Astley Cooper, op. cit., p. 385. 



786 COMPOUND DISLOCATIONS OF THE LONG BONES. 

two were compound ; T and of one hundred and sixty-six dislocations 
in ray record of personal observation, only eight were compound. 2 

Relative Frequency in the Different Joints. — In my own recorded cases, 
four were dislocations of the tibia inwards at the ankle-joint, one was 
a partial (pathological) luxation forwards at the same joint, one was a 
luxation of the astragalus, one a luxation of the head of the humerus 
into the axilla, and one a forward luxation of the radius and ulna at 
the wrist-joint. I have also met with several examples of compound 
dislocations of the fingers. Both of the cases reported by Norris were 
dislocations of the thumb. 

Sir Astley Cooper, speaking upon this point, says that the elbow, 
wrist, ankle, and finger joints are most subject to these accidents ; and 
that he has seen but two in the shoulder-joint, and one in the knee- 
joint. He had never seen a compound dislocation at the hip-joint, and 
he believed that it was "scarcely ever" so dislocated. Mr. Bransby 
Cooper has, however, reported in detail a very interesting case of this 
accident, communicated to him by Dr. Walker, of Charlestown, Mass., 
in which reduction was accomplished by manipulation alone, by Dr. 
Ingalls on the second day. The patient died at the end of about three 
w T eeks. 3 So far as I know, this is the only case upon, record. Mal- 
gaigne says that a compound dislocation at the hip-joint has probably 
never occurred. 

Among the cases of compound dislocation recorded by Sir Astley 
and Bransby Cooper, most of which were communicated to these gen- 
tlemen by other surgeons, forty-five were dislocations of the ankle, ten 
of the astragalus, four of the ulna at the wrist-joint, four of the thumb, 
two of the knee, one of the shoulder, one of the elbow, one of the radius 
and ulna at the wrist, one of the scaphoid bone, and one of the meta- 
tarsal bone of the great toe. Other writers have occasionally described 
compound dislocations of the clavicle, but I know of no record of a 
compound dislocation of the lower jaw. 

Prognosis, as determined by the Mode of Treatment adopted by most of 
the Ancient and many of the Modern Surgeons. — By most of the early 
writers these accidents, whenever they occurred in the larger joints, 
were regarded as nearly beyond the reach of art. Says Hippocrates : 
" In cases of complete dislocation at the ankle-joint, complicated with 
an external wound, whether the displacement be inwards or outwards, 
you are not to reduce the parts, but let any other physician reduce 
them if he choose. For this you should know for certain, that the 
patient will die if the parts are allowed to remain reduced, and that 
he will not survive more than a few days, for few of them pass the 
seventh day, being cut off by convulsions, and sometimes the leg and 
foot are seized with gangrene." Hippocrates adds : " But if not re- 
duced, nor any attempt at first made to reduce them, most of such cases 



1 Norris, Amer. Journ. M*ed. Sci., April, 1841, p. 335. 

2 For the most of these eases, see Transactions of the New York State Med. Soc. 
for 1855, article entitled " Report on Dislocations, with especial rel'erence to their 
Results," by F. H. Hamilton. 

3 A. Cooper, on Dislocations, etc., by B. Cooper, p. 59. 

4 Works of Hippocrates, Sydenham ed., London, vol. ii, p. 634. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 787 

The same remarks are applied by Hippocrates to compound disloca- 
tions of the head of the tibia, of the lower end of the femur, of the 
wrist, elbow, and shoulder joints ; death occurring in all cases, as he 
believes, more or less speedily whenever the bones are reduced and 
retained in place a sufficient length of time, and " were it not that the 
physician w T ould be exposed to censure," he would not reduce even the 
bones of the fingers, since it must be expected, he thinks, that their 
articular extremities will exfoliate even when the reduction is most 
successful. 

I shall presently show, however, that even Hippocrates advised and 
probably practiced resection in certain cases of these accidents. 

Both Celsus and Galen adopt almost without qualification the line 
of practice laid down by Hippocrates, and affirm equally the danger 
and almost certain death consequent upon the reduction of compound 
dislocations in large joints. 1 Celsus recommends resection in some 
cases. 

Paul us JEgineta, however, and after him Albucasis, Haly Abbas, 
and Rhazes, do not regard the rules established by Hippocrates, in re- 
lation to the non-reduction of the bones, as so imperative, nor the 
results of the opposite practice as so uniformly fatal. 

"Hippocrates remarks," says Paulus iEgineta, "in the case of dis- 
locations with a wound, the utmost discretion is required. For these, 
if reduced, occasion the most imminent danger, and sometimes death, 
the surrounding nerves and muscles being inflamed by the extension, 
so that strong pains, spasms, and acute fevers are produced, more par- 
ticularly in the case of the elbows, knees, and joints above, for the 
nearer they are to the vital parts the greater is the danger they induce. 
Wherefore, Hippocrates, by all means, forbids us to apply reduction 
and strong bandaging to them, and directs us to use only anti-inflam- 
matory and soothing applications to them at the commencement, for 
that by this treatment life may sometimes be preserved. But what he 
recommends for the fingers alone, we would attempt to do for all the 
other joints ; at first and while the parts remain free from inflamma- 
tion, we would reduce the dislocated joint by moderate extension, and 
if we succeed in our object, we may persist in using the anti-inflamma- 
tory treatment only. But if inflammation, spasm, or any of the 
aforementioned symptoms come on, we must dislocate it again if it can 
be done without violence. If, however, we are apprehensive of this 
danger (for perhaps, if inflammation should come on, it will not yield), 
it will be better to defer the reduction of the greater joints at the com- 
mencement ; and when the inflammation subsides, which happens about 
the seventh or ninth day, then, having foretold the danger from reduc- 
tion, and explained how, if not reduced, they will be mutilated for life, 
we may try to make the attempt without violence, using also the lever 
to facilitate the process." 2 

In the following quotations from three of the most celebrated writers 
of the last two centuries, we find but little if any evidence that the 

1 Paulus ^Egineta, Syd. ed., vol. ii, p. 510. 2 Ibid., p. 509. 



788 



COMPOUND DISLOCATIONS OF THE LONG BONES. 



opinions of the fathers upon this subject were not still held in general 
respect: If the joint be dislocated, so that it is either uncovered, or 
a little thrust forth without the skin, the accident is mortal, and of 
more danger to be reduced than if it be not reduced. For if it be not 
reduced inflammation will come upon it, convulsion, and sometimes 
death 2. There will be a filthiness of the part itself. 3. An incura- 
ble ulcer and if perhaps it be brought to cicatrize at all, it will easily 
be dissolved by reason of the softness of it; but if it be reduced, it 
brings extreme danger of convulsion, gangrene, and death." 1 

bi vero in magnis articulis tarn valida fuit facta luxatio, ut litra- 
mentis ruptisos articuli multum sit protrusum per integumenta, heec 
pars ossis vasis private moritur, citius autem si reponatur, quam si non 
repomtur ; quare sola amputatio restat ad conservationem vit« V2 

Heister, who makes no allusion to this subject in the first edition of 
his great work, published at Amsterdam in 1739, adds the following 
17«* «rV-\ > St ^ion translated and published in London in 
1- i -V lslocatlons attended with a wound, especially of the shoulder 
or thigh-bone, are of very bad consequence, and often endanger the 
lite of the patient; in- Celsus's opinion (Book VIII, Chap. XXV) 
whether the bones be replaced or not, there is generally great danger- 
and so much the more the nearer the wound is to the joint. Hippoc- 
rates has declared that no bones can be reduced with security, beside 
those of the hands and feet. (Vectiar. 19, 5.) See more on this sub- 
ject in that passage of Celsus just now quoted, though I by no means 
recommend the following him implicitly." 3 

Such were the extreme views as to the fatality of these accidents, 
and of the feebleness of our resources, entertained by the ancient, and 
even by the more modern writers almost down to our own day • with 
only rare exceptions these limbs were condemned either to great and 
inevitable deformity, or to amputation. Nor, if we speak only of 
their fatality, have surgeons ceased to regard these accidents as among 
the most grave with which they have to deal. 

Pathology^ and Appreciation of the Sources of Danger as compared 
especially with Compound Fractures. —The danger, according to Sir 
Astley Cooper, consists in the rapid inflammation of the synovial 
membranes, which is speedily followed by suppuration and ulceration, 
whereby the ends of the bones become exposed ; and for the repair of 
which lesions great general as well as local efforts are required, and a 
high degree of constitutional irritation results. In addition to which 
circumstances, " the violence inflicted on the neighboring parts, the 
injury of the muscles and tendons, and the laceration of bloodvessels, 
necessarily lead to more important and dangerous consequences than 
those which follow simple dislocations." 

The sources of danger enumerated by Sir Astley Cooper have been 
regarded as sufficient to account for their extraordinary fatality by the 

ed!, WU^L* St ° reh0USe - B ? Johannes Scultetus, of Ulme, in Suevia. London 

3 r T °on a i.?rsi e to G ° rt r q Chirur g i Y e r ) T Ur ^ ata - Lu £ duni Batavorem, 1742, t. 86. 
vol.?, i > 164 ^ of Surgery, by Dr. Laurence Heister. 8th ed. London, 1768, 



COMPOUND DISLOCATIONS OF THE LONG BONES. 789 

majority of those modern surgical writers who have alluded to the 
subject; but I must confess that to me they do not appear so. In 
compound fractures the mortality is far less ; yet one might naturally 
suppose, that when the sharp and irregular fragments are pressing into 
the flesh, among nerves and bloodvessels, the irritation and inflamma- 
tion would be equal, if not more than equal, to the irritation and con- 
sequent inflammation produced by exposing a joint surface to the air; 
indeed, modern experience has sufficiently shown that these surfaces 
are much more tolerant of atmospheric exposure, and of the action of 
many other irritants, than surgeons formerly supposed. A clean inci- 
sion into a large joint, which exposes the synovial membranes to the 
air, and which permits the products of inflammation to escape freely, 
is attended with much less danger than a small puncture which does 
not at all permit the air to enter, nor the increased synovia and the 
pus to escape. Very grave results sometimes follow from large wounds 
into large joints, but under judicious treatment such results are the ex- 
ception and not the rule. 1 But Sir Astley evidently attributes more of 
the bad consequences to the exhausting effects of the efforts at repair, 
than to the immediate inflammation resulting from the exposure of the 
joint. It is pretty certain, however, that a majority of these patients 
die at a period too early to render this cause in any considerable degree 
operative. 

As to the bruising of the " muscles and tendons, and laceration of 
bloodvessels," it cannot be denied that it must usually be greater than 
in "simple dislocations;" and I will not say that it is not in a given 
number of instances greater than in the same number of instances of 
compound fractures. The tissues have often been thrust rudely through 
by a large and smooth bone, and the tendons have been stretched vio- 
lently or torn completely asunder ; while occasionally large arteries, 
which are prone to hug the bones about the joints, are lacerated and 
left to bleed. That the importance of these complications, however, 
may not be overestimated, we must state that Sir Astley Cooper him- 
self has remarked how seldom, in compound dislocations of the ankle- 
joint, the large arteries are injured ; that a tearing of the ligaments and 
of the tendons is almost as likely to occur in simple dislocations as in 
compound; and, indeed, that in neither case are the tendons usually 
ruptured, but only thrust aside. Moreover, the skin is often made to 
give way not so much from the pressure of the round head within, as 
from the equal pressure of some sharp angular body from without. In 
all these respects, there are many examples of compound fractures 
which possess not a whit of advantage; in which cases, nevertheless, the 
surgeon feels very little doubt as to the ultimate cure. 

In short, the causes which, according to Sir Astley Cooper, deter- 
mine the extraordinary fatality of these accidents, do not sufficiently 
differ from those which operate in compound fractures to occasion so 
great a difference in results, and the fatality of compound dislocations 

1 Upon this point, see the very ;ihle article, entitled " Amputations and Compound 
Fractures," bv John O. Stone, in the New York Journal of Medicine, vol. iii, of 
2d series, p. 316, Nov. 1849. 



790 COMPOUND DISLOCATIONS OF THE LONG BONES. 

remains unexplained; or if surgical writers have here and there inti- 
mated the true cause, they have failed to give it its proper place and 
value. 

I think the cause of the greater fatality of compound dislocations 
over compound fractures is to be found in the simple fact that disloca- 
tions are generally reduced, and by splints or other apparatus success- 
fully maintained in place, while compound fractures, as my statistical 
report of cases has proven, are not generally reduced completely, nor 
can they by any means yet devised, except in a few cases, be main- 
tained in place if reduced. Broken limbs, whether simple or com- 
pound in their character, will in a great majority of cases shorten upon 
themselves in spite of the most assiduous and skilful attempts to pre- 
vent it. 1 

In adults most bones break obliquely, and cannot be made to sup- 
port each other, and even in transverse fractures the broken ends are 
generally small compared with the articular ends of the same bones, 
and afford a very uncertain and inadequate support for themselves ; not 
to sj)eak of the difficulty of once bringing their ends into exact apposi- 
tion where the muscles are powerful, or where they lie imbedded in a 
large mass of flesh so that they cannot be felt. While, on the other 
hand, dislocated bones, whether simple or compound, are capable, when 
restored to place, of supporting themselves; or with only slight assist- 
ance, their reduction may be maintained; it is also ordinarily a work 
of no great difficulty to reduce them. 

Herein, then, consists the most important difference between these 
two classes of accidents, which are in other respects so similar. In the 
one, the very nature of the injury prevents the complete reduction, and 
the consequent violent strain of the muscles, tendons, and other soft 
tissues ; while in the other, the nature of the accident leaves it in the 
power of the surgeon to reduce the bones, and modern surgery has in a 
great measure sanctioned the practice of maintaining them in place, 
in defiance of the efforts of the muscles, and sometimes, no doubt, at the 
imminent hazard of the life of the patient. 

Is it not fair to presume that tissues which have been stretched and 
lacerated, require rest in order that they may recover from the effects of 
their injuries? And if the soft parts are really more injured in dislo- 
cations than in fractures, does not the indication for rest become for 
this very reason, more imperative? 

General Inferences. — We have come, then, to regard the shortening 
of limbs after fractures, within certain limits and in certain cases, as a 
conservative circumstance rather than as a circumstance which the sur- 
geon should in all cases seek to prevent. 

There is abundant evidence that the ancients had some knowledge of 
the value of rest to the muscles, tendons, etc., in the prevention of in- 
flammation after compound dislocations, since they constantly urge the 
greater danger of reducing these dislocations, than of leaving them un- 
reduced; and they do not hesitate to recommend, that in case violent 

1 " Keport on Deformities after Fractures." Trans. Am. Med. Assoc., vols, viii, 
ix, and x. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 791 

inflammation supervenes upon the reduction, the bone shall immedi- 
ately be again dislocated. Galen speaks very explicitly on this subject, 
and says that "the danger in reduction consists partly in the additional 
violence inflicted on the muscles, and partly in their being then put 
into a stretched state, whereby spasms or convulsions are brought on, 
and gangrene as the result of the intense inflammation which ensues;" 
and Paul us ^Egineta remarks : " For these, if reduced, occasion the 
most imminent danger, and sometimes death ; the surrounding nerves 
and muscles being inflamed by the extension/' etc. 

I have already quoted from Sir Astley Cooper the causes or reasons 
which he has assigned for the fatality of compound dislocations ; and 
the same reasons have generally been assigned by those who have 
written since his day ; but he has elsewhere, when speaking of exsec- 
tion, given place to the very idea for which we claim so much promi- 
nence, the danger arising from a stretching of the muscles. Mr. Listen, 
also, and Mr. Miller, when speaking especially of dislocations of the 
tibia at the ankle-joint, refer to the same source of danger. 

Treatment. — Let us see now the alternatives which surgery presents 
for the treatment of these intractable accidents. 

1. Reduction of the bone. 

2. Non-reduction. 

3. Amputation. 

4. Tenotomy. 

5. Resection and reduction. 

The questions for us to consider are, first, by which of these several 
methods is the life of the patient rendered most secure? and second, 
where, of two or more methods, all are equally safe, by which will he 
suffer the least maiming or mutilation? 

By Reduction. — We have seen already how the old surgeons regarded 
the practice of reducing compound dislocations of the larger joints. It 
is not difficult, however, to find in the records of surgery numerous 
examples of successful terminations under this practice. 

Dr. White, of Hudson, N. Y., has reported a case of this kind in 
which the dislocation was at the ankle-joint. 1 Pott says he has seen 
this practice occasionally succeed, 2 and Mr. Scott communicated to the 
Lancet, in March, 1837, a case of compound dislocation of the humerus 
successfully treated by reduction. Sir Astley Cooper also records 
several cases of compound dislocations at the lower end of the tibia and 
fibula, successfully treated by reduction. 

A careful examination, however, of those cases reported by Sir 
Astley as having been reduced without resection, and which resulted 
in cures, does not in my opinion, leave much substantial evidence in 
favor of the practice ; or perhaps we ought rather to say that it leaves 
only a qualified evidence of its propriety in certain cases. He has 
mentioned about sixteen of these examples, comprising dislocations of 
the lower end of the tibia, or of the tibia and fibula, outwards, also 
inwards and forwards, all of which, save one quoted from Mr. Liston, 

1 White, Amer. Journ. Med. Sci., Nov. 1828, p. 109. 

2 Pott, Chirurg. Works, vol. ii, p. 243. 



792 COMPOUND DISLOCATIONS OF THE LONG BONES. 






have been reported to him by other surgeons, and not one of which 
had he ever seen himself. Many of the cases are reported very loosely, 
evidently in reply to circular letters, and from memory, without re- 
corded notes, and by unknown, and in some sense irresponsible sur- 
geons. It is not always said whether the wounds in the soft parts 
were made by the protrusion of the bones, or by some external violence; 
yet this is certainly a very material point in determining whether re- 
duction is to be followed by inflammation or not. The results, some- 
times only attained after exposure to great hazards, are, after all, often 
sufficiently unfavorable. 

It will be noticed, also, that in Cases 152 and 153, the astragalus 
was comminuted and removed, either at first or at a later day; and in 
Cases 154, 155, 156, and 160, the tibia, and also probably the fibula, 
were broken, and it does not appear but that in consequence of this 
complication the limb became shortened, and the muscles were thus 
put at rest, very much as if the bones had been retracted ; and in one 
of the cases enumerated under 161, the lower end of the tibia spon- 
taneously exfoliated. That a comminution or that any fracture of the 
astragalus, or of the tibia and fibula, should be regarded in these cases 
as rendering the accident less grave, can only be comprehended by a 
full appreciation of the value of relaxation of the muscles. 

The few cases which remain after this exclusion do indeed illustrate 
how nature and skill may triumph over great difficulties, but nothing 
more. 

It is possible, also, that some of these examples of recovery after 
reduction may admit of an explanation entirely consistent with our 
own views of the true source of the danger in these accidents, if indeed 
they do not tend actually to confirm our doctrines. I have myself seen 
one example of complete recovery after the reduction of a compound 
dislocation at the ankle-joint, although resection was not practiced; 
but in this case, all the tissues, or nearly all which suffered any injury, 
were completely torn asunder, and therefore wholly removed from the 
danger of which we have spoken. The example to which we allude is 
the following: On the 30th of Oct. 1858, John Bourquard, set. 30, was 
caught in the tow-line of a canal-boat, causing a compound dislocation 
of the right ankle-joint. I found the foot, immediately after the acci- 
dent, thrown completely back against the lower part of the leg, the 
integuments in front of the joint, as well as all of the tendons and 
ligaments on this side, being completely torn asunder, while the tendo- 
Achillis, and the tendons behind both of the malleoli, with the corre- 
sponding integuments, were uninjured. This immunity of the tissues 
behind the malleoli was due to the direction in which the foot was 
drawn, namely, directly backwards. Everything which had suffered 
a strain being thoroughly severed, I did not hesitate to attempt to save 
the limb without resection. The reduction was accomplished very 
easily. The leg and foot were placed in a box filled with bran, and 
cool water dressings were applied to the portion which was exposed. 
On the 22d of November the limb was removed from the bran to a 
pillow, the union being sufficient not to demand so much lateral sup- 



COMPOUND DISLOCATIONS OF THE LONG BONES. 793 

port. About the first of March he left the hospital, the wound having 
closed, but the ankle remaining swollen and stiff. 

I have also seen two cases in whicli the foot has been nearly severed 
from the leg through the ankle-joint, by means of a "reaper." In 
each case the patient was standing with his back to the machine, and 
one of the blades cut horizontally from side to side, severing everything 
except about three inches of integuments in front, and the extensor 
tendons of the toes. In the first instance, having seen the patient, a 
gentleman nearly sixty years of age, within three or four hours of the 
time of the receipt of the injury, I found him exceedingly exhausted 
by the haemorrhage. Bojth malleoli were cut off smoothly, the knife 
having severed the limb so exactly through the joint, as to have touched 
the cartilage at but one or two points. Having secured the bloodvessels, 
I replaced the foot, and after a few days of attendance I left him in 
the charge of an excellent young surgeon, Dr. Robertson, of Lancaster, 
N. Y., to whose diligence and skill the patient is no doubt mainly 
indebted for his recovery. After the lapse of nearly one year he was 
able, by the assistance of a shoe furnished with lateral supports, to 
walk very well. In the second case, which was only brought to my 
notice some months after the accident occurred, in consequence of a 
troublesome fistula near the ankle-joint, the recovery had been com- 
plete except that a small fragment of one of the malleoli was necrosed 
and required removal. 

Dr. Eli Hurd, of Niagara Co., N. Y.,was equally fortunate in a case 
of compound dislocation of the shoulder-joint. This was in the person 
of G. T., set. 30, who was caught in the gearing of a threshing-machine 
on the 18th of February, 1852, which, having drawn him in with great 
force, dislocated the head of the left humerus downwards through the 
integuments into the axilla. Reduction was accomplished according 
to the method recommended by Nathan Smith,, by pulling from each 
wrist at right angles with the body, while the operator himself seized 
the naked head of the humerus with his left hand, his right resting 
upon the top of the shoulder, and pushed it into place. The time 
occupied in the reduction was about thirty seconds. The forearm was 
then suspended in a sling, and the venous haemorrhage, occasioned by 
a rupture of the subclavian vein,. w r as arrested by compression. The 
tegumentary wound, between three and four inches in length, was 
subsequently closed by sutures,, and cool w T ater dressings were applied.. 
On the fourth day the wound had united by first intention, and the 
man was walking about his room. In less than a month he was dis- 
missed cured, and in the following harvest he was able to cut his ow r n 
hay and grain, and to use his arm as before the accident. 1 

Miller and Hoffman reduced successfully a compound dislocation of 
the knee, 2 and Galli has communicated a similar case to Malgaigne. 3 

Whether either of the last three mentioned examples admit of the 
same explanation as the preceding three, I am unable to say, but 

1 Hurd, Buffalo Med. Journ., vol. ix, p. 119. 

2 Miller and Hoffman, London Med. Eepos., vol. xxiv, p. 346'. 

3 Galli, Malgaigne, op. cit., t. ii, p. 958. 

51 



e 

! 



794 COMPOUND DISLOCATIONS OF THE LONG BONES. 

whether they do or do not, they are too exceptional in their character 
to prejudice the argument materially which we shall hereafter make 
in favor of resection. 

Non-Reduction. — On the other hand, it will be very difficult to find 
an equal number of cases of compound dislocations, unreduced, which 
have terminated favorably. The fact is, no doubt, that at the present 
day very few surgeons would feel themselves justified in leaving a 
bone out of place unless they proceeded to amputate. In the Trans- 
actions of the New York State Medical Society for 1855, I have re- 
ported (Case 16 of Tibia and Fibula, p. 87) a compound dislocation 
at the ankle-joint, which, being unreduced, .terminated fatally on the 
twenty-eighth day. This is the only example of a compound dislo- 
cation of a long bone, left unreduced, which has fallen under my ob- 
servation ; excepting, of course, those cases in which amputation was 
i m m ed iately practi ced . 

The united testimony, however, of the old surgeons, who generally 
neither amputated nor adopted the method of resection, but who rec- 
ommended and practiced non-reduction, is, that it is much more safe 
to leave these bones unreduced, than to reduce them without resec- 
tion; and I see no reason to doubt the correctness of their opinion 
in this matter. But whether it would be more safe to leave such 
limbs unreduced, or having practiced resection to restore them, is 
another question, in which the advantage and comparative safety of 
the latter practice are too obvious to require explanation or defence. 

Amputation. — Says Pott : " When this accident (dislocation of the 
ankle) is accompanied, as it sometimes is, with a wound of the integu- 
ments of the inner ankle, and that made by the protrusion of the bone, 
it not unfrequently ends in a fatal gangrene, unless prevented by 
timely amputation, though I have several times seen it do very well 
without." And Sir Astley Cooper, speaking of compound dislocations 
of the ankle-joint, remarks : " Thirty years ago it was the practice to 
amputate limbs for this accident, and the operation was then thought 
absolutely necessary for the preservation of life, by some of our best 
surgeons." Nor is it difficult to see by what reasoning surgeons of 
"thirty years ago" had fallen back upon this desperate remedy. Both 
reduction and non-reduction having proven eminently hazardous, in 
the absence of perhaps both knowledge and experience in resection, 
they finally adopted the alternative of amputation, as that which after 
all must give to the patient the best chance for life; and were no other 
alternatives to be presented, this would be our choice in a large pro- 
portion of cases. 

It must not be understood, however, that amputation is an expedient 
wholly free from danger; or, indeed, that the chances of the patient 
are in the average very greatly increased by this practice. Of thirteen 
amputations made for compound dislocations at the ankle-joint, in the 
Royal Infirmary at Edinburgh, only two resulted in the recovery of 
the patients. 1 Alluding to which, Mr. Fergusson remarks : "An 
amount of mortality which may well incline the surgeon to act upon 

1 Edinb. Med. Monthly, Aug. 1844. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 795 

the doctrine inculcated by Sir Astley Cooper " (to attempt to save 
the limb by reduction). But Mr. Fergusson has added a sentiment 
which accords very closely with my own experience and opinions. 
" I fear, however, that in the attempts which have been made to save 
the foot (by reduction), the results in all the cases have not met with 
the same publicity — that the instances where amputation has been 
afterwards necessary, or where death has been the consequence, have 
not always been recorded; and, from what I have myself seen, I would 
caution the inexperienced practitioner from being over-sanguine in 
anticipating a happy result in every example." 

By Tenotomy. — As a- means of overcoming the resistance of the 
muscles, and for the purpose especially of facilitating the reduction, 
tenotomy has been proposed. First by Dieffenbach in cases of ancient 
unreduced luxations; but Wm. Hey, Jr., was the first to make a prac- 
tical application of this suggestion in a case of compound dislocation. 
After cutting the tendo-Achillis, the ankle being dislocated, the reduc- 
tion was easily effected, but a strong tendency to displacement back- 
wards remained, and he was obliged afterwards to cut the tendons of 
the tibialis posticus and flexor longus digitorum. 1 

This method, based in some degree upon a very correct notion of 
the principal sources of difficulty, I regard as totally impracticable, 
at least to any useful or adequate extent. In order to be efficient, all 
the tendons passing the articulations must be cut, or nearly all of 
them ; and I doubt whether the judgment of any discreet surgeon will 
ever sanction such an extreme, I might almost say such an absurd, 
measure. Nor do I think that in the point of view in which we are 
now considering this subject, having reference only to the question of 
danger, if the cutting of the tendons was sufficiently extensive to have 
any real effect in facilitating the reduction, the practice would be found 
to have any advantage over other methods known to be eminently 
dangerous. 

By Resection. — Finally, resection presents itself for our consideration 
as the only remaining surgical expedient. 

We have seen that most of the early writers understood the effects 
of a constant strain upon the muscles in increasing the danger of 
spasms, inflammation, and death ; but in general they have suggested 
no remedy but non-reduction or amputation. Hippocrates, however, 
uses the following language, after speaking of resection of protruding 
bones in accidental amputations or in fractures of the fingers : " Com- 
plete resection of bones at the joints, whether the foot, the hand, the 
leg, the ankle, the forearm, the wrist, for the most part, are not at- 
tended with danger, unless one be cut off at once by deliquium animi, 
or if continued fever supervene on the fourth day." To which pas- 
sage the translator adds the following note : " This paragraph on resec- 
tion of the bones in compound dislocations and fractures contains 
almost all the information on the subject which is to be found in the 
works of ancient medicine." Celsus notices the practice of resection 
in compound dislocations very briefly, as follows : "Si nudum os emi- 

Med. and Surg. Assoc, vol. xii, p. 171, 1844. 






796 COMPOUND DISLOCATIONS OF THE LONG BONES. 

net, imped i men turn semper futurura est; ideo quod excedit, abscin- 
dendum est." 

Mr. Hey, of Leeds, was the first of modern surgeons who called 
especial attention to the value of resection in compound dislocations. 

Subsequently, Mr. Parks, of Liverpool, in an "Account of a New 
Method of treating Diseases of the Joints of the Knee and Elbow," 
advocates the practice of resection in certain cases of diseases of these, 
joints, but especially in "affections of the joints produced by external 
violence." 

Mr. Leveille, in France, also following, as he affirms, the guidance 
of Hippocrates, has advocated a similar practice. 

Velpeau, Sy me, Fergusson, Erichsen, Miller, Liston, Chelius, Lizars, 
Gibson, Norris, under certain circumstances, and especially where the 
bones cannot otherwise be reduced, and where the dislocations occur 
in certain joints, and especially the elbow and ankle joints, recommend 
resection. To which names we may add that of Sir Astley Cooper, 
who has considered the subject, as applied to the ankle-joint, quite at 
length, and who says : " I have known no case of death when the 
extremities of the bone" (tibia, at the ankle) "have been sawed off, 
although I shall have occasion to mention some cases which terminated 
fatally when this was not done." 

Why resection should diminish the danger to life, by placing at 
rest the injured muscles, has been already sufficiently considered; but 
it seems not improbable that, if synovial membranes are actually more 
susceptible of violent and dangerous inflammations than the other 
tissues about the joints, then would this source of danger be removed 
just in proportion as the synovial membranes themselves are removed. 
Such, indeed, was the argument used by Sir Astley ; and Mr. South, in 
a note to Chelius, when referring to this fact, has made the following 
statement : 

" In compound dislocations of the ankle-joint, with protrusion of 
the shin-bone through the wound, most English surgeons saw off the 
joint end, not merely to render reduction more easy, but also, accord- 
ing to Sir Astley Cooper's opinions, to lessen the suppurative process, 
by diminishing the synovial surface. This mode of practice is cer- 
tainly not commonly followed in reference to other joints, and the 
younger Cline was always opposed to its being resorted to in dislocated 
ankle." 

The following cases having occurred under my own eye, will serve 
to illustrate the value of the principle which I have been endeavoring 
to establish : 

Samuel Adam son, of Buffalo, set. 24, was caught by the cable of a 
vessel, June 17th, 1855, dislocating the left tibia at its lower end in- 
wards, and breaking the fibula two inches above the ankle. I was 
immediately called, and found the tibia protruding through the skin 
about three inches. The periosteum was torn up, and the cartilaginous 
surface of the end of the bone was roughened. His thigh was also 
severely bruised and lacerated, but the bone was not broken. 

Dr. Boardman assisting me, we attempted to reduce the bones, but 
with our hands we found it impossible to do so. I proceeded imme- 






COMPOUND DISLOCATIONS OF THE LONG BONES. 797 

diately to remove about one inch and a half of the lower end of the 
tibia with the saw. The remaining portion was then brought easily 
into place, and the wound dressed with sutures, adhesive straps, band- 
ages, and light splints. On the same day he became an inmate of the 
marine wards at the Hospital of the Sisters of Charity, and was placed 
under the care of Dr. Wilcox, through whose politeness I was permitted 
to see him frequently. 

The wound in the leg healed kindly, with only a slight amount of 
inflammation and suppuration. Violent inflammation, however, oc- 
curred in the thigh, followed by extensive suppuration and sloughing. 
This, in fact, proved to be by far the most serious injur} 7 , and that 
which most endangered his life and delayed his recovery. 

After about two months, the ankle was in such a condition as to 
require little or no further attention. The fragments of the fibula had 
shortened upon each other and were united, so that the tibia rested 
upon the astragalus. It was nearly two months, however, before he 
began to walk, owing to the condition of his thigh. 

August 24, 1856, fourteen months after the accident, Ad am son called 
at my office. He was then employed again as a sailor on board the 
schooner Sebastopol, and performed all the duties of an ordinary deck- 
hand. His leg is shortened one inch and a quarter ; from which, it 
seems, that there has been some deposit upon the end of the bone, which 
has compensated for one-quarter of an inch of that which I removed. 
The ankle is perfect in its form, being neither turned to the right nor 
to the left, and he treads square and firm upon the sole of his foot. 
There is considerable freedom of motion, especially in flexion and ex- 
tension. Occasionally it becomes a little swollen and painful. 

January 1, 1875, Rosanna Wilbur, set. 45, was admitted to ward 13, 
Bellevue, having just been injured by a street car. She was in good 
health, but very fat, weighing 185 lbs. She was found to have a com- 
pound dislocation at the right ankle-joint — the tibia being thrust com- 
pletely through the flesh — and also a fracture of the fibula. Dr. Lewis, 
the house surgeon, reduced the dislocation at once, and easily, and 
then sent for me. I advised an attempt to save the limb without 
resection, and by supporting the limb with the plaster of Paris dress- 
ing. This dressing was applied fourteen hours after the accident by 
Dr. Lewis, a window being made opposite the ankle. January 3, the 
window was enlarged. January 5, gangrene and phlebitis had occurred ; 
fenestra again enlarged. January 7, entire splint laid open, and hot- 
water dressings applied. January 12, suspended limb. January 21, 
the condition of the limb very critical; and, in a consultation composed 
of the visiting surgeons, we were equally divided between amputation 
and resection. It was permitted, therefore, that I should choose my 
own course. I immediately resected two inches of the lower end of 
the tibia, and placed the limb again in a sling supported with com- 
presses as means of lateral support, and warm-water dressings were 
continued. The subsequent progress of the case was very slow, and 
there were several smart attacks of erysipelas, so that her life was at 
times in danger; but finally all unfavorable symptoms disappeared, 
and on the 1st of May, the ankle was in perfect shape, admitting of 



798 COMPOUND DISLOCATIONS OF THE LONG BONES. 

some flexion and extension, and the wounds were almost completely 
closed. It is now apparent, that a resection on the first day would have 
been the most judicious practice, but that even at a later day it saved 
her life. 

In a case of compound dislocation of the upper end of the humerus, 
occurring also under my own observation, and recorded in the Trans- 
actions of the New York State Medical Society for 1855 (p. 27, Case 14), 
in which reduction was followed by death, I have now much reason to 
believe that if I had practiced resection before the reduction, my pa- 
tient's chances for recovery would have been greatly increased ; perhaps 
also the case of compound dislocation at the wrist-joint recorded in 
the same volume (p. 68), in which, having reduced the bones, I was 
subsequently compelled to amputate, may equally illustrate the hazard 
to which the practice of reduction without resection must often expose 
the patient. 

The same remarks I will venture to apply to the case of compound 
dislocation of the hip, of which I have already spoken as having oc- 
curred in the practice of Dr. Walker, of Charlestown, Mass. Had the 
head of the femur been resected before its reduction, I cannot doubt 
but that the unfortunate man's chance for recovery would have been 
very greatly improved. 

Thus, if we consider the question of the life of the patient only, the 
argument and the testimony seem to favor resection in a great majority 
of cases of compound dislocations occurring in large joints, and in a 
considerable number of cases of similar accidents in the smaller joints. 
It is certainly more safe than non-reduction or reduction without resec- 
tion, and it is probably quite as safe as amputation or tenotomy. 

But there is another question, which is, in our estimation, secondary 
to the one now considered, but which is often in the estimation of the 
patient himself of the first importance, namely, by which method will 
he suffer the least maiming or mutilation? 

This question I do not find it difficult to answer. Certainly it is 
not by non-reduction or by amputation ; and, putting tenotomy aside, 
it is now a question only between reduction without resection, and re- 
duction with resection. These two methods, one of which experience 
has shown to be fraught with danger, and the other of which experi- 
ence has shown to be relatively safe, are now to be compared in a point 
of view in which their antagonisms are perhaps less conspicuous, ye 
sufficiently marked. 

First. In either case the inflammation consequent upon the injury 
may be violent, and the recovery slow and tedious. The same argu 
ments, however, which we have applied to the question of the com 
parative danger of the two modes, must apply with nearly equal force 
to this question of maiming; since the amount of maiming must often 
be governed by the intensity and duration of the inflammation, and 
upon this point the testimony has been shown to be in favor of re- 
section. 

It will be observed that not only is the danger of maiming rendered 
more considerable by reduction without resection, because the inflam- 
mation is so much more likely to extend to the tendons and muscles, 






': 



COMPOUND DISLOCATIONS OF THE LONG BONES. 799 

causing them to adhere to each other, and to become subsequently 
atrophied, a condition from which they often never completely recover, 
but also because the ligaments and capsules of the joints, with the 
synovial surfaces, are in consequence encroached upon, and the free- 
dom of motion is ever afterwards greatly restricted, if not completely 
lost. This marked impairment of the functions of the joint does not 
always happen, but it cannot be denied that it does generally. Indeed, 
it is by no means uncommon for these accidents to be followed, after 
ulcerations of the cartilage, by copious bony deposits in and around 
the joints. 

How is it, on the other hand, Avith these joints after resection ? I 
have thus far heard of no cases in which complete anchylosis resulted; 
but in all considerable freedom of motion has returned, and in some 
the restoration in this respect has been nearly or quite as complete as 
before the accident. 

Says Dr. Kerr, of Northampton : " Several cases of compound dis- 
location of the ankle have fallen under my care, and it has been uni- 
formly my practice to take off the lower extremity of the tibia, and to 
lay the limb in a state of semiflexion upon splints; by this means a 
great degree of painful extension, and the consequent high degree of 
inflammation, are avoided. The splints I used are excavated wood, 
and much wider than those in common use, with thick movable pads 
stuffed with wool. I keep the parts constantly wetted with a solution 
of liquor ammonise acetatis, without removing the bandage. In my 
very early life, upwards of sixty years ago, I saw many attempts to 
reduce compound dislocations without removing any part of the tibia; 
but, to the best of my recollection, they all ended unfavorably, or, at 
least, in amputation. By the method which I have pursued, as above 
mentioned, I have generally succeeded in saving the foot, and in pre- 
serving a tolerable articulation." 

Sir Astley Cooper has made a valuable experiment to determine the 
condition of the new joint under these circumstances ; and the vast 
number of cases in which resection has now been practiced in cases 
of caries of the articulating surfaces, and their results, add still more 
substantial proofs as to the usefulness of the joints after such opera- 
tions. 

" I made an incision upon the lower extremity of the tibia, at the 
inner ankle of a dog, and cutting the inner portion of the ligament of 
the ankle-joint, I produced a compound dislocation of the bone in- 
wards. I then sawed off the whole cartilaginous extremity of the 
tibia, returned the bone upon the astragalus, closed the integuments by 
suture, and bandaged the limb to preserve the bone in this situation. 
Considerable inflammation and suppuration followed ; and in a week 
the bandage was removed. When the wound had been for several 
weeks perfectly healed, I dissected the limb. The ligament of the 
joint was still defective at the part at which it had been cut. From 
the sawn surface of the tibia there grew a ligamento-cartilaginous sub- 
stance, which proceeded to the surface of the cartilage of the astragalus 
to which it adhered. The cartilage of the astragalus appeared to be 
absorbed only in one small part ; there w T as no cavity between the end 



800 COMPOUND DISLOCATIONS OF THE LONG BONES. 



of the tibia and the cartilaginous surface of the astragalus. A free 
motion existed between the tibia and astragalus, which was permitted 
by the length and flexibility of the ligamentous substance above de- 
scribed, so as to give the advantage of a joint where no synovial articu- 
lation or cavity was to be found. This experiment not only shows 
the manner in which the parts are restored, but also the advantage of 
passive motion ; for if the part be frequently moved, the intervening 
substance becomes entirely ligamentous ; but if it be left perfectly at 
rest for a length of time, ossific action proceeds from the extremity of 
the tibia into the ligamentous substance, and thus produces an ossific 
anchylosis." 

Second. Is it not probable, moreover, since the limb can be retained 
in place so much more easily after resection, that it will actually, in a 
majority of cases, be found to have been retained in place more per- 
fectly? Even after simple dislocations, especially in those occurring 
at the ankle-joint, great deformity and much maiming are the not un- 
frequent results, and that too when all diligence and care have been 
employed. It has been impossible always to maintain a perfect appo- 
sition in the articulating surfaces. How much greater must be this 
difficulty in cases of compound dislocations. 

Third. The only argument which remains in favor of reduction 
without resection is the necessary shortening of the limb after resection. 
But this need seldom perhaps to exceed three-quarters of an inch, and 
often not more than half an inch ; an amount of shortening which, as 
I have had occasion to prove when treating of fractures, does not neces- 
sarily produce a halt, and which indeed is often not known to exist by 
the patient himself. The experience of Heine, Langenbeck, Volkman, 
Hueter, and other German surgeons, has shown that in a considerable 
number of cases, when these resections have been made by the subperi- 
osteal methods, no shortening whatever has resulted. 1 

Finally. It must not be inferred that the author intends to recom- 
mend resection as a universal practice in cases of compound dislocations 
of the long bones. He has only sought to determine in a general 
manner its relative value as compared with other modes of procedure; 
and especially has it been his intention to bring more prominently into 
view the importance of rest and relaxation to the muscles, as an ele- 
ment in the treatment most essential to success. To declare its special 
application to cases would demand a treatise more elaborate than it was 
proposed to write. If, however, one were to speak of the individual 
bones only, there seems sufficient authority in the facts and arguments 
already presented to conclude that resection is applicable to certain 
compound dislocations of the clavicle, humerus, radius, and ulna, fingers, 
femur, tibia, fibula, and toes; in short, to a certain proportion of all 
these accidents occurring in the long bones of the extremities. 

If an attempt is made to save the limb without resection, it is scarcely 
necessary to say that the success will depend, in a great measure, upon 
the care, attention, and skill bestowed upon the treatment. Cool or 



1 On Subperiosteal Resection of the Tibio-tarsal Articulation. By Achilles Rose, 
M.D., New York. The Medical Record, July 3, 1875. 



CONGENITAL DISLOCATIONS. 801 

tepid water-dressings, according as the indications or the sensations of 
the patient seem to demand, are among the most valuable remedial 
agents. The limb must be maintained in a position of rest, combined 
with moderate elevation ; and the bran-dressings, recommended in com- 
pound fractures, will be found occasionally useful. 



CHAPTEE XXVI. 

CONGENITAL DISLOCATIONS. 

I 1. General Observations and History. 

We have omitted, until this moment, to speak of Congenital Dislo- 
cations, because, whatever theory of causation we adopt, dissections 
have shown that they are generally, in some sense, pathologic, or are 
accompanied with such essential modifications of the anatomical struc- 
tures as to separate them entirely from ordinary traumatic luxations, 
which alone constitute the proper subjects of consideration in the present 
treatise. In relation to congenital dislocations, w r e shall find it neces- 
sary to establish systems of etiology, symptomatology, prognosis, and 
treatment, having very few points in common with traumatic disloca- 
tions. Exceptions to this rule will occur, in examples of intra -uterine 
traumatic luxations, existing at birth without either original or acci- 
dental malformations of the articulations, or of the adjacent muscular, 
tendinous, or ligamentous structures ; yet only in sufficient numbers to 
warrant the intrusion of the subject in this place. 

It is probable that congenital displacements may occur in all the ar- 
ticulations of the skeleton; and in most of them their existence has 
been already established by dissections. Until within a few years, 
however, the attention of surgeons has been almost entirely directed to 
congenital dislocations of the shoulder and hip. 

Hippocrates, in his treatise "De Articulis," speaks expressly of dis- 
locations of the hip occurring in the mother's womb, comprising them 
under the same order with the different varieties of club-foot. 

Avicenna and Ambrose Pare have each mentioned original disloca- 
tions of the hip ; but the first to record an example with any degree 
of accuracy was Kerkring; in which case, death having occurred 
during infancy, he was able to verify his opinion by an autopsy. 
Chaussier has reported, in the Bulletin de la Faculte et de la Soeiefe de 
Medecine, An. 1811 and 1812, the case of an infant, upon which he 
discovered, at birth, two dislocations, one at the scapulo-humeral artic- 
ulation, and the other at the coxo-femoral. In 1788, Palletta, of Milan, 
published, under the title of Adversaria Chirurgica, a collection of 
observations, in which, among other things, he has described certain 
congenital malformations of the hip-joint; and in 1820 he published 



802 CONGENITAL DISLOCATIONS. 

another work, entitled Excrtitationes Pathologicce, where he enters into 
a more complete exposition of the nature and causes of these deformities. 

In 1826, Dupuytren read, before the Academy of Sciences, a memoir 
upon the lameness produced by the original displacement of the femur; 
and in the Logons Orales, published in the collections of the Sydenham 
Society, may be found a full record of the views and observations of 
this distinguished surgeon. 

The writings of Dupuytren seem, more than anything previously 
written, to have directed the attention of surgeons and pathologists to 
this interesting subject, and to have given a new impulse to investiga- 
tion. 

From this time various treatises have been written by eminent sur- 
geons, many of which are characterized by profound thought, careful 
investigation, and practical experiment. 

Among those who have furnished us lately with elaborate treatises, 
or with more precise practical information upon this subject, the fol- 
lowing names deserve to be especially mentioned : Breschet, 1 Caillard 
Billioniere, 2 Lehoux, 3 Sandiforte, 4 Duval and Lafond, Humbert and 
Jacquier, Bouvier, 5 Sedillot, 6 Gerdy, Poliniere, Wrolik, 7 Guerin, 8 Pa- 
rise, 9 Pravaz, 10 Carnochan, 11 and Robert Smith. 12 









I 2. Etiology. 

Hippocrates says that the bones of the extremities may be disarticu- 
lated during intra-uterine life by falls or blows, or by injuries of any 
kind, inflicted directly upon the abdomen of the mother. 

Ambrose Pare, while admitting the efficiency of the several causes 
named by Hippocrates, believed also that the contractions of the 
womb, and violence employed by the accoucheur, were occasionally 
adequate to the production of the same results. He taught, moreover, 
that the position of the foetus itself might favor the displacement; and 
that, in some instances, an articular abscess, insufficient depth of the 
socket, with a laxity of the ligaments, were competent to determine the 
expulsion of the head of the femur from its natural position. 

1 Breschet, Repertoire d'Anatomie et de Physiologic 

2 Caillard-Billioniere, These Inaugurale, 1828. 

3 Lehoux, These Inaugurate, 1834. Paris. 

4 Sandiforte, Thesis, sustained before the Faculty of Med. of Leyden. 

5 DuvhI and Lafond, Humbert and Jacquier, Bouvier. See Pravaz. 

6 Sedillot, Jolirn. de Connais. Med -Chirurg., 1838. 

7 Gerdy, Poliniere, Wrolik. See Pravaz. 

8 Gue>in, Reeherches sur les Luxations Cong6nitales ; par Jules Guerin. Paris, 
1841. 

9 Parise, Archiv. Gen. de Med., 1842. 

10 Pravaz, Traite Theorique et Pratique des Luxations Congenitales du Femur, 
suivi d'un Appendice sur la Prophylaxie des Luxations Spontanees ; par Ch. G. 
Pravaz, Lyons, 1847. 

11 Carnochan, A Treatise on the Etiology, Pathology, and Treatment of Con- 
genital Dislocations of the Head of the Femur; by John Murrav Carnochan, New 
York, 1850. 

12 R. Smith, A Treatise on Fractures in the Vicinity of Joints, and on Certain 
Accidental and Congenital Dislocations. Dublin, 1854. 



ETIOLOGY. 803 

Sedillot regards a softening and relaxation of the ligaments as the 
most frequent cause. 

Parise and Malgaigne are disposed to attribute a majority of these 
cases to hydrarthrosis, or water in the joints. Says Malgaigne: " For 
myself, after having long meditated upon this subject, I have come to 
think that inflammation of the joints enjoys a grand role, both in 
coxo-femoral dislocations and in many others, and even also in various 
congenital malformations generally ascribed to arrest of development." 
This writer admits, however, that it will not do to generalize too much 
in this matter, and that the etiology of congenital luxations is proba- 
bly as complex as that of luxations after birth. 

Chaussier seems to have regarded muscular contraction, or the oc- 
currence of an intra-uterine convulsion, as the cause of the example of 
congenital dislocation of both humerus and femur seen and recorded 
by him. Since whom Gu6rin has greatly extended the application of 
this doctrine, having embraced in the same etiologic formula all or 
nearly all congenital dislocations. Guerin ascribes to muscular con- 
traction in one form or another, and to corresponding muscular paraly- 
sis, not only dislocations of the femur and other long bones, but also 
club-foot, torticollis, and various other deviations of the spine. He 
affirms, moreover, that he has established incontestably the dependence 
of this abnormal state of the muscular system upon the absence or 
disappearance more or less complete of corresponding portions of the 
central nervous systems. 

Breschet and Delpech maintained similar views, especially in rela- 
tion to the dependence of the several varieties of club-foot upon some 
morbid condition of the cerebro-spinal axis. While Carnochan re- 
marks as follows : " It appears most in accordance with science to 
refer the muscular spasmodic retraction, upon which congenital dislo- 
cations of the head of the femur from the cotyloid cavity depend, to a 
perverted condition of the excito-motor apparatus of the medulla 
spinalis, and more especially of that portion of it which is in direct 
relation with the reflex-motor nervous fibres, distributed to the pelvi- 
femoral muscles surrounding, and in connection with, the ilio-femoral 
articulation." 

Palletta ascribes these deformities solely to an original defect of the 
germ ; and Dupuytren also declares that, in the case of a congenital 
dislocation of the hip, the causes are coeval with the earliest organiza- 
tion of the parts, and that the displacement is due rather to a defect 
in the depth or completeness of the acetabulum, than to accident or 
disease. 

Breschet and Delpech, both of whom, as we have already stated, 
refer them to some morbid condition of the cerebro-spinal axis, im- 
agine that in consequence of this morbid condition of the nervous 
centres, there exists an arrest of development in the bones, muscles, 
ligaments, sockets, and, in short, through all the apparatus of the joint 
which is the seat of the deformity. 

If we proceed to analyze these various opinions, we shall find that 
they are so far susceptible of classification, as that they may be ar- 
ranged under the three following divisions: 



804 CONGENITAL DISLOCATIONS. 

First, the physiological doctrines ; according to which congenital 
dislocations are due to an original defect in the germ, or to an arrest 
of development. 

Second, the pathologic doctrines ; which refer them to some sup- 
posed lesion of the nervous centres, to contraction or paralysis of the 
muscles, to a laxity of the ligaments, to hydrarthrosis, or to some other 
diseased condition of the articulating apparatus. 

Third, the mechanical doctrines; which recognize no intra-uterine 
dislocations except those which are strictly traumatic. The causes 
being understood to be the peculiar position of the foetus in utero, 
violent contractions or the constant pressure of the walls of the uterus, 
falls and blows upon the abdomen, and unskilful manipulation of the 
child in delivery. 

After a full and careful consideration of this subject, we are prepared 
to admit the occasional agency of all the causes enumerated, and the 
probable concurrence of two or more in many instances; nor do we see 
the propriety of rejecting, as Malgaigne has done, all that large class 
of malformations, which seem to depend upon an arrest of development, 
or those which appear to be due mainly or solely to intra-uterine pa- 
ralysis, of both of which many examples have been reported. 

§ 3. Congenital Dislocations of the Inferior Maxilla. 

Malgaigne affirms that "we know of no congenital dislocation of the 
jaw," and that we are " not to take seriously the pretended luxation 
observed by Guerin upon a d6renc6phalous infant." The example 
recorded by Robert Smith he rejects also, declaring that he does " not 
comprehend how one can see in it a luxation." 

For myself, I know of no reason why we should not take "seriously " 
the case mentioned by Guerin, since, so far as appears in his very brief 
report of the same, it might have been a true luxation. The specimen 
was before the Academy, and if Malgaigne, from a personal examina- 
tion, has become satisfied that a dislocation did not exist, he ought to 
have so informed us. But since he does not speak of having made it 
the subject of especial examination, we shall feel compelled to accept 
of it as reported by Guerin. 

As to the objection offered to Mr. Smith's case, namely, that " aside 
of the complete absence of its history, the subject did not present the 
characteristic signs of luxation, and the dissection discovered neither 
maxillary condyle nor glenoid cavity," we must reply, the dissection 
seems to us to have furnished such evidence that the deformity was 
congenital as to render its history unnecessary ; the signs were charac- 
teristic, not indeed of a traumatic luxation, but of a congenital disloca- 
tion, such as may be supposed to have been the result of an arrest of 
development, or of an original aberration of the germ. 

The following is a summary of the very complete account of this 
case given by Robert Smith. 

On the 5th of May, 1840, Edward Lacy, set. 38, an idiot from in- 
fancy, died at the Hardwick Hospital, in consequence of gangrene of 
the lungs. While making the autopsy, a singular deformity of the 



CONGENITAL DISLOCATIONS OF INFERIOR MAXILLA. 805 

face was discovered. The right and left sides seemed as though they 
did not belong to the same individual, the left being in every respect 
more fully developed. Upon removing the integuments, the muscles 
of the right side were found to be much smaller than those of the left, 
and especially the masseter. These latter having been removed also, 
the condition of the right temporo-maxillary articulation was carefully 
studied. 

AVhen the mouth was closed, the external lateral ligament, instead 
of being directed backwards, was seen descending obliquely forwards, 
to be attached to a very imperfectly developed condyle situated at 
least one-quarter of an inch in front of its natural position. There 
was neither an interarticular cartilage nor cartilage of incrustation, 
the joint surfaces being invested by a thick periosteum alone; nor was 
there any distinct capsular ligament. 

Xearly the whole of the right side of the inferior maxilla was 
smaller than the left. The condyle was short and curved, being 
directed nearly horizontally inwards, and resembling much more the 
coracoid process than the condyle of the inferior maxilla. The coro- 
noid process was very small and thin, and the sigmoid notch could 
scarcely be said to exist. 

The articular eminence of the temporal bone was absent, there being 
in its place nearly a flat surface destitute of cartilage; which surface 
presented upon its inner side a shallow and semicircular sulcus where 
the hooklike condyle of the lower jaw had played. 

The malar, superior maxillary, and sphenoid bones of the right side 
had also suffered corresponding changes of form and relative size. 

The motions permitted in the lower jaw were more extensive than 
those which it enjoys in its normal condition, that is, upon the right 
side the ramus could be moved very freely forwards and backwards, 
while upon the left, the condyle underwent a species of rotation upon 
its axis. During life the patient was observed to be constantly per- 
forming this motion, and the right side of the face was continually 
affected with spasmodic twitches. When the mouth was closed, the 
front teeth of the upper jaw projected beyond those of the lower, and 
when opened the deformity was in all respects greatly increased. 1 

Mr. Smith takes this occasion also to express his dissent from the 
views maintained by Ribes, namely, that the formation of the glenoid 
cavity is consequent upon the growth of the condyle, and that, were 
this process not formed, there would not exist either a glenoid cavity 
or an articular eminence. It is true that neither the glenoid cavity 
nor the articular eminence is found in the foetus. Until the seventh 
month of intra-uterine life there exists at this point of the temporal 
bone only a plane surface, and the glenoid cavity with its correspond- 
ing eminence is developed in proportion to the growth and develop- 
ment of the condyle. But Mr. Smith justly observes that although 
the development of the condyle does precede that of the glenoid cavity, 
¥ it by no means follows that the formation of the latter is due to the 
pressure of the former." The cavity, or rather the transverse eminence 

1 Robert Smith, op. cit., p. 283. 



806 CONGENITAL DISLOCATIONS. 

in front of the plane surface, does not exist in foetal life, because, 
to the peculiar form of the inferior maxilla at this period, its existence 
is not necessary. The vertical portion of the jaw (vertical only in the 
adult) is in the foetus nearly in the same line with the axis of the shaft, 
and consequently when the mouth is opened by the action of the mus- 
cles, the condyles are pressed upwards and backwards instead of up- 
wards and forwards, as in the adult. A displacement forwards cannot 
therefore very well occur; and the protection of the articular eminences 
is not required. As age advances the angles of the jaw increase, the 
portions upon which the condyles rest become more vertical, and finally 
a displacement forwards would occur whenever the mouth was well 
opened if the articular eminences were not present to afford a sufficient 
protection in front. 

In the case of Lacy the foetal condition of the bones upon one side 
remained during life, there being neither cavity nor eminence, and the 
condyle itself being only imperfectly developed ; but the angle of the 
jaw had assumed the form which belongs to the adult, and the ascend- 
ing ramus was vertical, consequently the condyle became somewhat 
displaced forwards. 

Chronic rheumatic arthritis is occasionally found in the temporo- 
maxillary articulation of old persons; and it may be important to dis- 
tinguish it from congenital luxation, with which, owing to the absorp- 
tion of the aiticular eminence, and the consequent displacement of the 
condyle, it might possibly be confounded. 

Says Mr. Smith : " In a majority of instances, this remarkable dis- 
ease attacks those of advanced age, and is symmetrical; but occasion- 
ally it occurs during the period of adult life. In the latter case it is 
generally more rapid in its progress, is accompanied by greater pain, 
and is more liable to implicate the neck of the condyle, and the ramus 
of the jaw." 

When the condyle is implicated it becomes enlarged, and can be felt 
beneath the zygoma, in front of the meatus externus. The lymphatic 
glands of this region are sometimes enlarged, and the progress of the 
malady is attended with a constant but not generally severe pain. 

The deformity of the face varies according as one or both articula- 
tions are affected. When the malady is confined to one joint, the chin 
is thrown slightly forwards, but chiefly to the opposite side, and when 
both are implicated, the chin is simply advanced so that the teeth pro- 
ject beyond those of the upper jaw. 

As the disease progresses, the glenoid cavity enlarges by absorption, 
and at length a considerable portion or the whole of the articular emi- 
nence disappears and the jaw becomes gradually displaced through the 
action of the external pterygoids. The disease does not extend in the 
temporal bone beyond the articulating surface of the glenoid cavity. 
The condyle assumes a variety of forms, sometimes being greatly en- 
larged in all its diameters, while its upper surface may be flattened, or 
conical. The interarticular cartilage disappears ; but Mr. Smith has 
never yet found any foreign bodies in the joint, and in only one in- 
stance have the surfaces been polished or eburnated as we often see in 



COXGEXITAL DISLOCATIONS OF THE SPINE. 807 

examples of chronic rheumatic arthritis occurring in the hip, knee, and 
other joints. 

The following is an excellent summary of the diagnostic marks be- 
tween congenital, accidental, and rheumatic dislocations, given by this 
writer : 

u 1. In the congenital luxation, the mouth can be freely opened and 
closed; in chronic rheumatism these motions can be performed, but 
hot without uneasiness to the patient, an uneasiness which sometimes 
amounts to severe pain ; in luxations from accident, the mouth cannot 
be closed. 

"2. An involuntary flow of saliva accompanies the accidental luxa- 
tion alone, although in some cases of chronic rheumatism there is an 
increased secretion of that fluid. 

"3. In congenital luxation, the teeth of the upper jaw project be- 
yond those of the lower ; the reverse is observed in accidental luxation 
and in chronic rheumatism. 

" 4. In congenital luxation there is no fulness in the cheek, such as 
the coronoid process produces in cases of accidental luxation, and the 
condyle is not enlarged, as in some instances of chronic rheumatic 
arthritis." l 

\ 4. Congenital Dislocations of the Spine. 

Says Guerin, of the subluxation occipito-atloidean there are two 
varieties : " First. Backwards, consisting in an exaggerated flexion of 
the head upon the front of the neck and chest, with a commencement 
of sliding backwards of the occipital condyles upon the articular facets 
of the atlas. Here are two examples in foetal anencephalous monsters. 
Second. Forwards. Those who follow my consultations can recollect 
having seen last year an infant, about two or three months old, who 
offered a remarkable example. The head was exactly applied against 
the posterior part of the neck, and upper part of the back. There was 
probably a sliding of the condyles forwards, with elongation of the 
anterior ligaments." 2 

The existence of the first of these varieties has since been denied 
by Guerin himself; 3 and it will be noticed that he only speaks of the 
second as a. probable subluxation forwards. Neither of them can there- 
fore be regarded as established. 

Guerin further remarks that he has observed subluxations in the 
other regions of the spinal column many times; and he showed to the 
Academy a foetus in which the spine presented, besides the occipito- 
atloidean displacement, a series of angular flexions in the antero-poste- 
rior direction, with sliding of the articular surfaces. 

In attempting to appreciate the value of Guerin's observations upon 
this point, it must be remembered that he regards all cases of congeni- 
tal torticollis, and other deviations of the spine, as examples of sublux- 
ation ; and, in some sense, we think the theory of this distinguished 
surgeon may be regarded as correct. The amount of articular displace- 

1 K. Smith, op. cit., p. 292. 2 Guerin, op. cit., 1841, p. 29. 

3 Ibid., op. cit., p. 32. 



808 CONGENITAL DISLOCATIONS. 

ment between each of the adjacent vertebra? may be very inconsiderable 
in any such case, yet, however trivial, if it exceeds the limits of natu- 
ral motion, it may properly enough be regarded as the commencement 
of a luxation. 

§ 5. Congenital Dislocations of the Pelvic Bones. 

Bassius speaks of a diastasis or separation of the sacro-iliac symphy- 
sis, observed by him in newly born children, and in infants ; but, ac- 
cording to Malgaigne, his account of these cases is not such as to war- 
rant any conclusions as to the true nature of the displacements. 

Congenital exstrophy of the bladder is accompanied always with a 
deficiency of the central and upper portions of the pubic bones, the 
result manifestly of an arrest of development; but these cases, of which 
I have seen several examples, are not properly examples of congenital 
dislocations, but only of diastases, the separated portions remaining in 
their normal position with reference to each other, except that they are 
not prolonged sufficiently to meet in the median line. 

Guerin declares, however, that he has seen congenital displacement, 
or overriding of the iliac bone upon the sacrum, accompanied with coxo- 
femoral dislocation and curvature of the spine. The same writer men- 
tions an example, in a foetal monster, of diastasis of the pubic bones, 
and of the sacro-iliac symphysis, accompanied with a turning out of the 
pubes upon the external face of the ischium. 1 

\ 6. Congenital Dislocations of the Sternum. 

Seger alone has reported one example of luxation of the xiphoid car- 
tilage from the sternum. 

A woman in her fifth month of pregnancy fell and dislocated her 
shoulder. Just four months after this she was brought to bed with an 
infant, well formed, except that, soon after it was born, the ensiform 
cartilage was observed to be remarkably movable, especially when the 
child hiccoughed, to which it was very subject. The cartilage was 
separated from the sternum by the breadth of the little finger. No 
treatment was employed ; the cartilage gradually became restored to its 
place, and in about one year it was firmly united to the sternum. 2 

\ 7. Congenital Dislocations of the Clavicle. 

Malgaigne says that a congenital dislocation at the sterno-clavicular 
articulation has never been observed; but Guerin declares that he has 
established the existence of three varieties, namely : 

1. A luxation of the sternal end of the clavicle inwards and for- 
wards ; this extremity of the clavicle lying in front of the sternal four- 
chette. In illustration of which he presented to the Academy a plaster 
cast of a girl eight years old, in whom the displacement existed upon 
both sides. 

1 Ibid., Gaz. Med., 1851, p. 227. 

2 Seger, Ephem. Nat. Curios., 1677, from Malg., op. cit , p. 410. 



CONGENITAL DISLOCATIONS OF THE SHOULDER. 809 

2. Inwards and upwards. Observed by him in a girl eight years 
old ; but which displacement took place only when the arm was moved, 
and through the contraction of the sterno-cleido-raastoideus muscle. 

3. Backwards. Of which he presented two examples in the corre- 
sponding sides of a foetal monster. 

I believe I have already referred to Fergusson's case of dislocation 
of the sternal end of the clavicle forwards, which occurred during birth. 
The end rested in front of the sternum, and could be pushed into its 
place with great ease ; but when left alone it immediately slipped out 
a^ain. Nothing was done, a new joint formed, and the child after- 
wards possessed as much power in the one arm as in the other. 1 

Guerin says that he has seen a dislocation upwards and outwards at 
the acromial end of the clavicle in a foetus of three months. 

In regard to the treatment of either of these displacements of the 
clavicle, we need only remark that a reduction ought to be attempted ; 
and, if practicable, without much confinement of the little patient, it 
should be maintained until the bones have become fixed in their natural 
positions. It is quite probable that this can never be accomplished, at 
least perfectly ; but it will nevertheless be proper always to make the 
attempt. 

§ 8. Congenital Dislocations of the Shoulder. (Upper end of the 

Humerus.) 

Guerin affirms that he has established the existence of three varieties 
of scapulo-humeral dislocations, namely: 

1. Dislocations of the head of the humerus downwards; of which 
variety he presented to the Academy a plaster cast taken from a boy 
ten years old. The displacement existed in both arms, but much more 
pronounced in the right than in the left arm. It was due wholly to 
paralysis of the muscles about the joint, and to elongation of the cap- 
sule. 

2. Downwards and inwards ; complete upon one side and incom- 
plete upon the other, in the same person. The head of each humerus 
was applied against the ribs, and the arms maintained in an abduction 
almost horizontal, under the influence of the retraction of the deltoid 
muscles. " The same case/' Guerin remarks, " has been confirmed bv 
Roux." 

3. Subluxation upwards and outwards ; seen on both sides in a 
foetal monster, which was offered to the Academy for examination ; 
and in one arm of a young man fifteen years old, of which Guerin 
presented a plaster cast. "It is characterized by a sliding of the head 
of the humerus in the direction indicated; this sliding being favored 
by a corresponding displacement of the coracoid and acromion pro- 
cesses/' 2 

Malgaigne, who regards " all luxations in consequence of paralysis 
as essentially posterior to birth," will not admit the first example men- 

1 Fergusson, System of Surg., 4th Amer. ed., 1853, p. 203. 

2 Guerin, op. cit., p. 30. 

52 



810 CONGENITAL DISLOCATIONS. 

tinned by Guerin ; but, as we stated before, the objections made by 
Malgaigne have failed to convince us of the propriety of rejecting all 
of tins class of reported examples. Of the second case, mentioned by 
Guerin as having been confirmed by Roux, Malgaigne declares that he 
has consulted Roux upon this matter, and that he affirms that "he has 
never seen a congenital luxation of the shoulder." 

Robert Smith has met with but two of the forms of congenital 
luxation of the humerus described by Guerin, namely, that in which 
the head of the humerus is displaced forwards, and that in which it 
is displaced backwards. Of the first variety he has seen several ex- 
amples. 

The first was in the person of Alexander Steele, set. 29, who pre- 
sented both a dislocation of the head of the humerus. under the cora- 
coid process of the left scapula, and pes equinus in the foot of the left 
leg. The muscles of the arm and shoulder upon that side were feeble 
and greatly atrophied. The humerus was shortened ; its head being 
of the natural size and form, but when the arm hung by the side it 
dropped so far from its socket as to permit the thumb to be placed 
between the head and the acromion process. By pressing the humerus 
forwards, the finger could be placed in the outer part of the glenoid 
cavity ; and, although the head could be moved about thus freely, 
it seemed naturally to occupy only the anterior half of the glenoid 
fossa. 

Robert Smith's second example of subcoracoid congenital luxation 
was presented in the person of Mr. H., set. 20, the condition of whose 
left shoulder resembled almost precisely that of Mr. Steele. "The 
deformity had existed from his birth, but became much more obvious 
and striking as he increased in age and stature." 

In the third example the child had attained nearly the age of one 
year before the condition of the limb attracted attention, which was 
then excited, not by the deformity of the shoulder, but by the atro- 
phied condition of the muscles of the arm. The child had never com- 
plained of pain about the joint, nor had he ever met with any acci- 
dent. No doubt this also was an example of paralysis, and it is not 
improbable that it was congenital, but the evidence upon this point is 
not very conclusive. When seen by Mr. Smith, he was nine years old, 
the shoulder and arm presenting the same appearance as in the other 
cases mentioned. 

The fourth was also subcoracoid and symmetrical, the same de- 
formity existing in both shoulders. This was in the person of a 
female, set. 21, who had been for many years a patient in a lunatic 
asylum, and wh© died of chronic inflammation of the meninges of the 
brain. 

Mr. Smith, who himself made the autopsy, first noticed the condi- 
tion of the left shoulder. The muscles were atrophied ; the head of 
the humerus could be felt lying under the coracoid process ; the elbow 
projected from the side, but could be readily brought into contact with 
it. The right shoulder presented the same appearance, but the de- 
formity was somewhat less, and the head of the humerus was not so 
directly underneath the coracoid process. 



CONGENITAL DISLOCATIONS OF THE SHOULDER. 811 

From the external appearances presented by the two shoulders, Mr. 
Smith did not doubt that these deviations from the natural state of the 
parts were not the result of violence. 

Proceeding to remove the soft parts upon the left side, scarcely any 
trace was found of a glenoid cavity in its natural situation, but imme- 
diately underneath the coracoid process, upon the costal surface of the 
scapula, was formed an oblong socket completely surrounded by a 
capsular ligament, which ligament included also that small portion of 
the original socket which remained. The head of the humerus was 
changed in form, being oval, and fitted, in some measure, to both the 
old and new sockets, upon which it seemed to rest alternately. 

Upon the right side, although the condition of the bones was some- 
what different, the characteristic features of the deformity were similar. 

Malgaigne, who quotes Mr. Smith as saying that these dislocations 
must have been congenital, and for no other reason than because they 
were symmetrical, has scarcely done this author justice. Says Mr. 
Smith : " The position of the glenoid cavity, the remarkable form of 
the head of the humerus, the presence of a perfect glenoid ligament,, 
the absence of any trace of disease, and the existence of the deformity 
upon each side, all indicate the original nature of the malformation." 

The only example of backward luxation seen by Mr. Smith was also* 
symmetrical, and seems to be equally well authenticated. This was in 
the person of a woman named Doyle, a?t. 42, a lunatic also, who died 
February 8, 1839, in Dublin. She had been a patient in the lunatic 
asylum fifteen years, and was subject to severe epileptic convulsions, 
which ultimately proved fatal. 

Mr. Smith made the autopsy on the day following her death. The 
convolutions of the brain were small and atrophied, as is frequently 
observed in idiots. 

The two shoulders resembled each other so perfectly, both in external 
appearance and in their anatomy, that Mr. Smith has only found it 
necessary to describe particularly the condition of one. 

The coracoid process was remarkably prominent, but the acromion 
was not so prominent as in accidental dislocations of the shoulder.. 
The head of the humerus could be seen and felt distinctly moving 
with the shaft, upon the dorsal surface of the scapula. On removing 
the integuments, muscles, etc., no trace of a glenoid cavity was found 
in its natural situation; but upon the external surface of the neck of 
the scapula was a well-formed socket, which received the head of the 
humerus. Tins socket was covered with a cartilage of incrustation, 
and surrounded by a perfect capsule. The tendon of the biceps arose 
from the top and internal margin of the socket. The form of the 
acromion process was changed; the capsule smaller than natural; the 
head of the humerus irregularly oval, its anterior half alone being in 
contact with the glenoid cavity; the great tubercle natural, but the 
lesser was elongated and curved, forming a process of an inch in 
length, around the base of which the tendon of the biceps muscles 
played. 1 

1 Robert Smith, op. cit.. 



h 

i 



812 CONGENITAL DISLOCATIONS. 

Gaillard relates the ease of a female child, upon whom the left arm 
was discovered to be deformed a few days after birth, and the elbow 
separated from the side. Later, the arm was found to be nearly im- 
movable, and only at the end of four years was the dislocation recog- 
nized ; but no attempt at reduction was then made. When sixteen 
years old, she was seen by Gaillard, who found the head of the hume- 
rus in the infra-spinous fossa. The scapula, clavicle, and arm were 
preteruaturally small ; the forearm, although well developed, could 
not be completely extended nor supinated. 

Despite these unfavorable circumstances, Gaillard determined to 
make an attempt to accomplish the reduction. Four times in the 
space of eight days he submitted the arms to extension made at right 
angles with the body, by means of sixteen-pound weights, the exten- 
sion being continued from twenty to twenty-five minutes, and occasion- 
ally his own exertions being added to the weights. On the fourth 
attempt, the head of the bone was drawn gradually forwards, and by 
rotatory motion it was finally made to slip into its socket; but it be 
came immediately displaced. The next day Gaillard reduced it anew, 
and retained it in place one hour. Six days later it was again reduced, 
and, by the aid of bandages, permanently retained in place. The 
slight pain and swelling which followed soon disappeared; and by the 
aid of careful exercise, at the end of two years the arm had increased 
in length, and the patient could use the arm and hand so much better 
than before, as to encourage a hope that the recovery would be com- 
plete. 1 

Aristide Rodrigue, of Hollidaysburg, Penn., in a letter to the editor 
of the American Journal of Medical Sciences, gives the following brief 
account of a case of intra-uterine dislocation of the shoulder, compli- 
cated with a fracture of the forearm. 

" The woman, when about four months gone with child, fell on her 
left side, striking a board, and felt herself much hurt at the time : at 
the full period she was delivered of a full-grown large boy with the 
following deformity: dislocation of the humerus into the axilla; frac- 
ture of both bones of the forearm of left side, lower third. Dislocation 
could not be reduced ; union of the bones of the forearm by ossific 
matter complete ; bones passing each other, and hand at an angle of 
about 40° ; the child did well otherwise; now, four years old, strong 
and healthy; humerus has grown nearly apace with the other; forearm 
has not, and remains short and deformed as in birth ; the hand is of 
the same size with that of the sound side." 2 

I 9. Congenital Dislocations of the Radius and Ulna Backwards. 

It is not uncommon to meet with examples of a slight subluxation 
backwards of these bones in feeble and newly-born infants ; which 
condition is probably due to a relaxation and elongation of the capsule. 
It is characterized by a preternatural mobility of the joint, and espe- 
cially by the circumstance that the limb is capable of abnormal exten- 

1 Giiillard, Mem. de l'Acad. de. M6d , 1841, from Malg., p. 569. 

2 Kodrigue, loc. cit., Jan. 1854, p. 272. 



CONGENITAL DISLOCATIONS OF HEAD OF RADIUS. 813 

sion, or flexion backwards, as it is sometimes called. Guerin has seen 
this condition more advanced, the bones of the forearm having actually 
overlapped somewhat upon the lower end of the humerus, so that the 
articular surface of this latter presented itself in the fold of the elbow. 
This was especially observed in a girl of fourteen and a boy of thirteen 
years, and also in the two arms of a foetal monster. 1 

Chaussier relates that a young woman, at the commencement of the 
ninth month of pregnancy, perceived suddenly movements of the foetus 
so violent that she almost lost her consciousness. These movements 
were repeated three times in the space of six minutes, after which 
everything returned to its natural order, and the accouchement took 
place naturally and at the usual term. The infant was pale and feeble, 
and presented a complete backward luxation of the radius and ulna. 2 

I 10. Congenital Dislocations of the Head of the Radius. 

Examples of this luxation have been reported by Dupuytren, Cru- 
veilhier, Sandiforte, Adams, Dubois, Verneuil, Deville, Robert Smith, 
and Guerin, most of which were in the direction backwards, some out- 
wards, but only one of them forwards ; some were double, the same 
deformity being presented in both arms, and others were single. In a 
few examples the dislocations were complicated with a consolidation of 
the radius to the ulna, and in others with a deficiency of the ulna or 
with some deformity indicating its congenital origin. 

Of the symmetrical or double dislocation backwards Dupuytren 
furnishes the following example, presented to him in 1830, by M. 
Loir : " The abnormal position which the head of either radius had 
assumed was at the back part of the lower extremity of the humerus, 
beyond which it extended for the space of at least an inch. This dis- 
position of parts was absolutely identical on the two sides, and had all 
the characters of a congenital affection." 3 

In January, 1866, John Fitzmorris, set. 19, was admitted to the 
Bellevue Hospital, laboring under a general scrofulous cachexy, in 
whose person I found a congenital dislocation of the heads of both 
radii, outwards. The luxations are complete. The ulnse are in place 
and of natural form, but their articulations at the wrist are loose. The 
same remark applies to all the other joints in the body. The power of 
pronation and supination is unimpaired, as well, also, as the power of 
flexion and extension. 

In the example of outward luxation, mentioned by Deville, there 
was an almost complete absence of the ulna, the head of the radius 
mounting upwards more than three centimetres above the level of the 
articulation. 4 

Guerin, who has described the only example of a forward luxation, 
says it was observed by him in a girl of seven years, and that it was 

1 Guerin, op. cit., p. 31. 

2 Chaussier, from Malgaigne, op. cit., t. ii, p 268. 

3 Dupuytren, Injuries and Dis. of Bones, p. 117. 

4 Deville, Bulletins de la Soc. Anat., 1849, p. 153. 



814 CONGENITAL DISLOCATIONS. 

symmetrical. The two radii lay in front of the humeri, near the 
coronary fossettes. 1 

I 11. Congenital Dislocations of the Wrist. 

Guerin thinks he has seen three forms of congenital luxation of the 
wrist. First, a dislocation forwards, characterized by a sliding of the 
wrist before the bones of the forearm, and by the projection posteriorly 
of the lower ends of the radius and ulna; seen in an infant of six 
months, and in two adults. Second, backwards and upwards; seen 
in a child of six years, and accompanied with an incomplete paralysis 
of all the muscles of the forearm and hand. Third, backwards and 
outwards ; in a girl of fourteen years, accompanied with incomplete 
paralysis. 2 

Guerin has also seen three examples of dislocation outwards in foetal 
monsters, and one of dislocation inwards, as the result of arrest of 
development. 

Robert Smith believes that the case of simple dislocation of the 
wrist or of the carpus forwards, mentioned by Cruveilhier in his 
Anatomie Pathologique, was an example of congenital luxation ; and he 
relates two other cases equally remarkable which came under his own 
observation. One was in the person of Deborah O'Neil, a lunatic and 
epileptic, who died when thirty-six years old. Both upper extremities 
were deformed from birth ; the right presenting an example of dislo- 
cation of the carpus forwards, and the left of dislocation of the carpus 
backwards. The dissection showed that there had been an arrest of 
development, especially in the bones of the forearm and carpus. The 
second was in the person of a young woman who died of phthisis in 
the Richmond Hospital; the right wrist presenting an example of 
congenital dislocation of the carpus forwards from arrest of develop- 
ment also. 3 

Marrigues describes a very singular congenital displacement which 
he found upon a newly born infant. The radius and ulna were widely 
separated below, and in the interspace was lodged the whole of the first 
range of the carpal bones ; the hand being strongly turned inwards. 4 

I 12. Congenital Dislocations of the Fingers. 

Chaussier found in a foetus the last three fingers of the left hand 
dislocated at the metacarpophalangeal articulation. The thighs, knees, 
and feet were also dislocated. 5 

A. Berard speaks of an incurvation backwards of the last two pha- 
langes of the fingers as having been occasionally seen in newly born 
children of the female sex; and Mal^aigne adds that he has himself 
seen a woman who had, from birth, all the phalangettes carried back- 

1 Guerin, op. cit., p. 31. 2 Ibid., p. 717. 

3 R. Smith, op cit., pp. 238, 251. 

4 Miirriguop, Malpiigne, from Journ. de M6d., 1775, t. ii, p. 31. 

5 Chaussier, Malgaigne, op. cit., t. ii, p. 751. 



CONGENITAL DISLOCATIONS OF THE HIP. 815 

wards to an angle of 135°, leaving the heads of the phalanges project- 
ing forward under the skin. 1 

Robert has seen, in a girl six years old, a congenital lateral luxation 
of the phalangette of the index finger, which was inclined outwards at 
an obtuse angle. The external condyle of the lower extremity of the 
proximal phalanx was slightly atrophied, and the internal presented a 
corresponding projection. Robert cut the internal lateral ligament by 
a subcutaneous incision, but without any favorable result. 2 

\ 13. Congenital Dislocations of the Hip. 

Dupuvtren thought that double dislocations of the hip-joint, as con- 
genital accidents, were more common than single dislocations, but in 
the experience of Pravaz the rule has been reversed, he having met 
with but four double dislocations in a total of nineteen. 

Congenital dislocations of the femur have been noticed much oftener 
in females than in males. Of forty-five examples mentioned by Du- 
puytren and Pravaz, only seven or ei^ht were males. 

They may be complete or incomplete. Of the complete luxations, 
four varieties have been noticed. 

Upwards and backwards, upon the dorsum ilii. This variety is by 
far the most common. 

Upwards and forwards ; the head of the femur resting upon the 
eminentia ilio-pectinea. 

Downwards and forwards into the foramen thyroideum ; of which 
variety Chaussier alone mentions one example; but Delpech found in 
an infant, born paralytic, the head of the femur lodged habitually wear 
the foramen thyroideum. 

Directly upwards ; seen by Guerin, Pravaz, and others ; the head 
of the femur being placed immediately without the anterior inferior 
spinous process of the ilium. 

Guerin has observed, moreover, a single variety of subluxation; 
characterized by the incomplete displacement of the head of the femur 
in the direction upwards and backwards, so that it rested upon the 
edge of the cotyloid cavity : " observed often in newly born children, 
and with those in whom the muscular dislocations are effected spon- 
taneously after birth. 7 ' 

Through the courtesy of Dr. Davis, of this city, I was permitted, in 
March, 1865, to see a child, the daughter of a gentleman residing in 
Victor, Monroe Co., X. Y., who was born in 1860, with dislocation of 
both knees and both hip-joints. The legs at the time of birth were 
doubled forward upon the thighs, the heads of the tibias resting upon 
the front of the femurs, one inch above the condyles, the thighs being 
at right angles with the body and the feet touching the abdomen. The 
knees were drawn closely together. The dislocation of the heads of 
the femurs was not at this time recognized. By constant pressure Dr. 
J. B. Palmer had succeeded, at the end of one year, in restoring the 

1 Berard, "Malgaigne, op. cit., p. 773. 

2 Kobert, from Malgaigne, op. cit., p. 773. 



816 CONGENITAL DISLOCATIONS. 

leg to position, the thighs remaining flexed ; but when two years old 
she began to walk with her body bent forwards. The displacement of 
the hip-bones was then first discovered. When four years old the 
sartorius and tensor vaginae femoris were severed, but with very little 
benefit. At the time of my examination she was five years old. The 
thighs were still flexed and adducted ; by pressure upon the knees the 
femurs could be slid upwards aud backwards upon the ilium one inch; 
on rotating the femurs the trochanters were observed to move upon a 
very short radius, indicating the entire absence of head and neck. She 
walked with the gait peculiar to these conditions. 

Both Delpech and Guerin have called attention to two varieties of 
what the latter terms pseudo-luxations; of which the first simulates 
a dislocation upwards and backwards, and the second a dislocation 
downwards and forwards. In these examples, the extreme adduction 
or abduction of the thighs might lead to a belief that the bones were 
dislocated, when in fact the abnormal position of the limbs is due only 
to muscular contraction, without actual articular displacement. 

In the remarks which follow we shall have special reference to that 
form of congenital dislocations of the femur in which the head of the 
bone rests upon the dorsum ilii, as being that which will be presented 
in a vast majority of cases, and which, characterized by the same 
general phenomena, may be regarded as typical of all the others. 

Symptomatology. — First. When the dislocation is double. 

In these examples the deformity is often found to be symmetrical; 
the opposite limbs being precisely the same length, and in the same 
relative positions; a circumstance which, when it exists, may render 
the diagnosis more difficult, or may cause it to be for a long time 
entirely everlooked. It is in such cases especially that the deformity 
is not usually discovered until the child begins to walk. 

The first circumstance which would naturally arrest our attention, 
if the person who is the subject of this double dislocation is stripped 
and placed erect before us, is the great apparent length of the arms 
and of the body in comparison with the lower extremities. We may 
next observe that the great trochanters are carried upwards and back- 
wards, so as to make a remarkable projection in this direction ; the 
lumbar portion of the spinal column is thrown very much forwards 
and the dorsal portion backwards. The thighs incline inwards, so as 
almost to cross each other; the whole of the lower extremities are 
imperfectly developed and feeble; the toes are generally pointed di- 
rectly forwards, or they may be noticed to turn inwards. 

When the person stands, and his limbs are not in motion, the heel 
is usually brought down fairly to the floor; but in walking, and 
especially in the attempt to run, he touches only the balls and toes of 
his feet. "When they are about to walk," says Pravaz, "we see them 
lift themselves upon the points of the feet, to incline the superior part 
of the trunk toward the member which is about to support the weight 
of the body, and to lift the other from the ground with an effort, in 
order to carry it forwards. At this moment one of the trochanters, 
that which corresponds to the column of sustentation, appears to 
approach the iliac crest more nearly than when the patient is standing 



CONGENITAL DISLOCATIONS OF THE HIP. 817 

upon his two feet." In consequence of which mobility of the thigh- 
bones, the patient assumes a peculiar waddling gait, which is not only 
ungraceful, but exceedingly fatiguing. 

The difficulty of progression is, however, very variable in different 
persons. Sometimes the patient requires no aid whatever, and at 
other times he cannot walk without assistance. Generally it increases 
with age. It is especially deserving of notice that in rapid progression 
the mobility of the heads of the femurs is appreciably less than in 
slow progression, which is explained by the more constant and vigor- 
ous contraction of the muscles about the joint, when the motions of 
the limb are rapid. 

In the recumbent posture, the thighs may be drawn down easily to 
almost, their natural positions. The only exception to this rule, ac- 
cording to Carnochan, "is when the head of the femur has escaped 
from the natural capsule in which it was originally inclosed, and a 
new socket has been formed upon the dorsum of the ilium." 

Abduction is performed with difficulty ; adduction and rotation, 
especially inwards, being less restricted. 

Second. When the dislocation is only upon one side. 

In these cases the symptoms are essentially the same as in the double 
dislocation; with only such slight differences and peculiarities as would 
naturally suggest themselves to the surgeon, and which will not, there- 
fore, demand from us a special consideration. 

Pathology. — The head of the femur is sometimes merely changed in 
form and consistence, the neck also undergoing corresponding altera- 
tions in its size, form, direction, etc.; at other times the head is absent 
altogether, and Avith it a considerable portion or the whole of the neck 
has disappeared. 

The pelvic bones are usually more or less deformed. The acetabu- 
lum may be entirely deficient, or it may present itself as an irregular 
bony protuberance, without cartilage, fibro-cartilage, or ligaments. 
Sometimes it exists as an oval or triangular cavity, which is expanded 
as its superior and posterior margin into a distinct fossa, where the 
head of the femur, descending from the dorsum ilii, occasionally rests. 
A new cavity is formed usually upon the side of the pelvis, which is 
shallow and without an elevated margin, or it may be deeper, and more 
complete in its construction, by the addition of an osseous border. In 
either case, the new socket is often lined with a true periosteum and 
synovial membrane ; but not unfrequently it is unprotected by any 
soft tissue, the surface being hard and polished like ivory. 

The head of the femur, having escaped from its original capsule, 
through a button-like opening, rests in this socket constantly. In still 
other examples the head of the femur remains within its capsule, and 
may be observed to play backwards and forwards between the two 
sockets ; or the head and neck being absorbed, and the capsule remain- 
ing entire, the latter is converted into a long narrow sac, somewhat 
contracted in its centre, or finally into a firm ligamentous cord, which 
being attached to the stunted upper extremity of the femur, limits its 
motions in the direction of the crest of the ilium. In this case no new 
socket is formed. 



818 CONGENITAL DISLOCATIONS. 

A portion of the pel vi-fe moral muscles are contracted, in consequence 
of an approximation of their points of origin and insertion, and re- 
maining in a state of comparative, if not absolute, inertia, they become 
atrophied, or pass into a condition of fatty degeneration, while other 
muscles, in consequence of the increased labor which they have to per- 
form, become hypertrophied, or degenerate into a fibrous tissue. 

Treatment. — Says Dupuytren : " Of what possible utility can it be 
to practice extension of the lower extremities in these cases, even sup- 
posing the limbs could be thus brought to their natural length? Is 
it not evident that the head of the femur, finding no cavity fitted to 
receive and hold it, would, when abandoned to itself, resume its former 
abnormal position ? There is something more rational and feasible 
in adopting a palliative course of treatment. When we call to mind 
the natural proneness which the heads of thigh-bones have to ascend 
to the external iliac fossae, and that this tendency is partly due to the 
superincumbent weight of the body, and in part to muscular action, a 
just conception may be formed of the indications on which the employ- 
ment of palliative remedies should be founded. The object should be 
to relieve the lower limbs of the superincumbent weight on the one 
hand, and on the other to moderate the muscular action. Both of 
these indications are in part fulfilled by repose ; and the attitude most 
conducive to this effect is the sitting posture, in which the weight o 
the upper part of the body is not transmitted to the lower extremities, 
but is centred in the tuberosities of the ischia. Therefore, laboring 
persons afflicted with this infirmity should be recommended to adopt a 
sedentary occupation, as a calling which requires much standing and 
walking about would dangerously aggravate their deformity. Yet 
one would scarcely be willing to condemn such individuals to per- 
petual repose ; and to avoid this it is necessary to discover some means 
for diminishing the inconveniences which attend the upright posture, 
the act of walking and other exercises. Experience has taught me 
hitherto but two methods of obtaining this important object: the first 
consists in the daily employment of a perfectly cold bath, in which all 
the body should be immersed for the space of three or four minutes, 
the head being protected by an oiled-silk cap ; the water may be fresh 
or salt; and the only precautions necessary to take are to avoid bath- 
ing when the body is in a state of perspiration, or when the catamenial 
discharge is present. These baths have a local, as well as general, 
tonic effect. The second method consists in the constant use, at least 
during the day, of a belt, which embraces the pelvis, fitting closely 
over the great trochanters, and keeping them at a constant height, so 
as to bind the parts together, and prevent that continual unsteadiness 
of the body which results from the loose connections of the heads of 
the thigh-bones. For the proper fulfilment of these indications, cer- 
tain precautions are necessary-in the construction of this cincture; in 
the first place, it should occupy the narrow interval between the crest 
of the ilium and great trochanters, completely filling this space, and 
therefore being about three or four fingers' breadth, according to the 
age and size of the patient. It should further be well padded with 
wool or cotton, and covered with doeskin, so that it may not abrade 



! 



CONGENITAL DISLOCATIONS OF THE HIP. 819 

the parts to which it is applied ; and there should be a piece let in on 
either side, so as to receive and support the trochanters without en- 
tirely covering them ; it should be buckled behind, and padded straps 
be carried under the thigh, and across the tuberosity of the ischium, 
on either side, to prevent the zone from slipping up. I do not mean 
to assert that I have ever succeeded in completely getting rid of the 
inconveniences of congenital dislocations of the thigh-bones, but I 
have prevented their increasing, and have rendered supportable what 
I could not cure. The testimony of some patients to the value of this 
treatment has been of a most unequivocal character ; for being worried 
by the pressure of the belt, they have laid it aside, but have speedily 
restored it again, as they found that without it they had neither a sense 
of firmness in the hip, nor confidence in walking." 

In relation to which opinions the same excellent writer subsequently 
made the following candid admission : " I at first thought that no bene- 
fit would be derived in these cases from the employment of continual 
traction on the lower extremities, for reasons already stated ; but the 
experiments of MM. Lafond and Duval tend to throw some doubt on 
the correctness of this conclusion. These distinguished practitioners 
tested the influence of extension, in their orthopaedic institution, on a 
child eight or nine years of age, who was the subject of double con- 
genital dislocation of the hip ; after the uninterrupted employment of 
this treatment for some weeks, I satisfied myself that the limbs had 
resumed their natural length and direction ; but I was not a little 
astonished to find that, after extension had been persisted in for three 
or four months continuously, the greater part of the beneficial results 
remained for several weeks undiminished. It would be idle, it is true, 
to generalize on this single case ; but as an isolated example of the 
utility of extension it is interesting, and it may be the forerunner of 
more important results." 1 

Since which time Humbert and Jacquier, who, as well as Duval 
and Lafond, confined themselves to the treatment of deformities, claim 
to have met with equal success in the management of these cases by 
extension alone; and, still more lately, Guerin of Paris, and Pravaz of 
Lyons, by the adoption of the same general principle more or less modi- 
fied, have added new triumphs, and greatly enlarged its application. 

The means recommended and practiced by Gu6rin, are : first, pre- 
paratory extension destined to elongate the muscles as much .as pos- 
sible; second, subcutaneous section of the muscles which mechanical 
extension has not sufficiently elongated ; third, extension of the liga- 
ments, and even, if extension does not suffice, their subcutaneous sec- 
tion ; fourth, manoeuvres destined to effect reduction ; fifth, treatment 
designed to consolidate the reduction, and consisting in the application 
of the apparatus proper to maintain the extension and separation of the 
divided tissues, and to retain the head of the femur in its place; finally, 
in the gradual execution of movements proper to complete the coapta- 
tion of the surfaces, and to establish, little by little, the physiological 
movements of the joint. 

1 Dupuytren, op. cit. , pp 176-178. 



820 CONGENITAL DISLOCATIONS. 



Other surgeons have confined their efforts to the reduction of the 
dislocation, and they have, consequently, abandoned all those cases in 
which, owing to the complete absence of the natural socket, or to the 
want of sufficient mobility in the limb, the reduction was deemed im- 
possible ; but Guerin has gone a step farther, and has sought to estab- 
lish a new socket upon some point of the pelvic bones as near as possible 
to its natural articular fossa. " The means which I adopt," says 
Guerin, "are based upon a recognition of the processes which nature 
employs for the attainment of the same purpose, and of which mine 
are but an imitation. I have shown that the essential condition of the 
formation of artificial cavities is perforation of the articular capsule, 
and the placing in contact of the luxated extremity with an osseous 
surface, and that the condition of the maintenance of this abnormal 
rapport is the intimate adherence of the borders of the rent with th< 
circumference of the new cavity. Now it appeared to me that art 
could realize, in all points, the conditions which preside at the spon- 
taneous formation of artificial joints. To this end I commence by 
practicing under the skin, and at the point corresponding to that where 
it is most convenient to fix the luxated extremity, scarifications of the 
capsule, down to the bone to which it is attached. By this means the 
dislocated extremity is placed in immediate contact with the bony sur- 
face upon which it reposes. It makes upon this point a beginning of 
the work of organization resulting from the adhesion and fusion of the 
scarified points with the corresponding points of this surface. Then, 
in order to circumscribe and imprison the luxated extremity, in this 
place of election, I practice all about deep scarifications, which tend t( 
excite the same work of organization and to establish fibro-cellular 
adhesions between the incised borders of the capsule and the contigu- 
ous bony surfaces. 

"Finally, when the fibro-cellular adhesions are supposed to be suf- 
ficiently solid to resist the movements of the new articulation, I pro- 
voke, little by little, the development of the cavity destined to embrace 
the luxated extremity by the means which nature herself employs in 
analogous circumstances ; that is to say, by circumscribed and frequent 
movements of this articulation." 1 

The treatment ought to be commenced as early as possible, no ex- 
amples of success having been recorded in persons over fifteen years of 
age; while the youngest child whose treatment is reported as successful 
was three years of age. 

For the purposes of making the requisite extension, and of main- 
taining the bone in place, Pravaz (who does not, however, adopt Guerin's 
practice of establishing for the head of the bone a new socket, but only 
seeks to reduce and maintain it in its old socket) has invented several 
forms of apparatus adapted to the different stages of progress in the 
treatment. Heine of Cannstadt, GueYin, and others, have also sug- 
gested special contrivances for the same purpose ; but no surgeon who 
understands fully the principle upon which the cure is supposed to be 

1 Guerin, op. cit., pp. 81-83. 



CONGENITAL DISLOCATIONS OF THE PATELLA. 821 

accomplished, will be at a loss for apparatus suitable for making the 
necessary extension, or for maintaining the reduction when once it has 
been effected. 

The length of time required for the completion of a cure, where a 
cure is possible, must vary according to the age and health of the 
patient, and according to the pathological condition of the joint, and 
may be found to extend from a few months to one or more years. It 
is unnecessary to say that where the accomplishment of the cure de- 
mands a period of several years, the treatment must be intermittent 
and greatly varied, so as to suit all the changing circumstances in the 
condition of the patient. 

Finally, if after a fair trial we fail to accomplish a cure, or if the 
condition of the child will not warrant even the attempt, we ought as 
far as possible to seek to prevent an increase of the deformity by such 
means as our ingenuity may suggest, or by such judicious appliances 
and general management as we have seen recommended by Dupuytren. 

South says that he has seen one case of double dislocation in which 
the walking was at first extremely difficult, but from the fifteenth year 
and onwards the patient so improved, that at the twentieth year scarcely 
any trace of the peculiar gait could be discovered. 1 

3 14. Congenital Dislocations of the Patella. 

Palletta found a dislocation of the patella in the cadaver of a young 
man, which he supposed to be congenital. 2 Michaelis has reported 
two cases ; one in a young man of seventeen years, and the other in a 
girl of fourteen, each of whom affirmed that it had existed from birth. 3 
Both of these examples presented themselves at the hospital on account 
of hydrarthrosis of the knee-joints, and Malgaigne, who had himself 
seen a similar case, is disposed to regard them all as examples of path- 
ological rather than congenital luxations. Periat reports a case in 
which the dislocation was only produced by walking, and in relation 
to the authenticity or pertinence of which Malgaigne seems also to en- 
tertain a doubt. 4 

South says that he has seen a congenital dislocation on both legs, in 
an aged man. The patellar rested entirely upon the outer faces of the 
external condyles, leaving the front of the knee-joint completely un- 
covered. When the limbs were extended the patella? could be easily 
made to resume their natural positions, but on the patient's making 
the slightest movement they were again displaced. The knees were 
very much inclined inwards, the feet outwards, and his gait was diffi- 
cult and unsteady. 5 

Dr. Samuel G. Wolcott, of Utica, N. Y., informs me that he has under 
observation a case similar to the one reported by South, in a healthy 
and otherwise well-formed and well-developed boy, set. 4. " When 
the legs are flexed the patellae slip outwards upon the external condyles 

1 South, Note to Chelius, op. cit. , vol. ii, p. 245. 

2 Palletta, Exercitationes Pathological, p. 91. 

3 Michaelis, Rev. Med.-Chirurg., torn, xv, p. 56. 

4 Periat, Malgaigne, op. cit., torn, ii, p. 932. 

5 South, Note to Chelius, op. cit., vol. ii, p. 247. 



822 CONGENITAL DISLOCATIONS. 

of the femurs, and on extending the legs the patellae resume their posi- 
tions in front of the knee-joints. This occurs at every step he takes. 
The knees are strongly inclined inwards, and the feet outward. His 
step is very insecure, and if accidentally he hits his feet or legs against 
anything in walking, he invariably falls." 

The most remarkable example, however, has been reported by Dr. 
E. J. Caswell, of Providence, R. L, inasmuch as no less than five 
members of the same family have double congenital dislocations of 
the patellae. The man who was the subject of Dr. Caswell's special 
examination is 43 years old, and possessed of a good constitution. 
The patellae lay upon the outer condyles, and are movable, performing 
their functions nearly as well as if placed in their proper positions. 
He walks without difficulty upon level ground, or upon an ascending 
plane, but great caution is required in descending. The right patella 
is longer and less movable than the left, and the muscles of both of 
his lower extremities are small. "In addition to his labor as an oper- 
ative, he cultivates a small farm." Dr. Caswell examined his son 
and found the same malposition, but less marked than in the case of 
the father. The father then stated that his own father, his sister, and 
the son of his half brother by the same father, had a similar de- 
formity. 1 

\ 15. Congenital Dislocations of the Knee. 

The head of the tibia has been found, at birth, dislocated forwards, 
backwards, inwards, outwards, inwards and backwards, outwards and 
backwards, and simply rotated inwards. 

Most of these luxations were incomplete ; and of them all, the dis- 
location forwards has been observed much the most often. 

A subluxation forwards of the head of the tibia has been seen by 
Gu&rin in a fcetal monster, accompanied with extreme retraction of the 
extensor muscles of the leg. 2 Cruveilhier has dissected a foetus affected 
with a similar subluxation. 3 

In these examples the displacement forwards at the articular surface 
was but slight, and the anterior flexion of the limb inconsiderable; 
but when the dislocation is complete, or nearly so, the deformity is 
in all respects very much increased; as the following examples will 
illustrate : 

Dr. D. H. Bard, of Troy, Vermont, has reported an example of 
complete anterior luxation of the tibia, seen by himself, in a new-born 
infant. The leg was found drawn forwards upon the thigh at an acute 
angle, so that the toes pointed toward the face of the child, and the 
bottom of the foot was directed forwards. By the application of mod- 
erate force, the limb could be straightened and even flexed completely. 
These motions inflicted no pain. It was especially noticed that in 
bringing down the leg from its position of extreme anterior flexion 
(extension) more force was required in the first part of the manoeuvre 
than in the last; and that if, having brought the leg down, it was left 

1 Caswell, Amer. Journ. ]tfed. Sci., July, 1865. 2 Guerin, op. cit., p. 33. 

3 Cruveilhier, Atlas de l'Anat. Patholog., 2e livr., pi. 2. 



CONGENITAL DISLOCATIONS OF THE KNEE. 823 

to itself, it immediately resumed the abnormal position, moving at first 
slowly, but after a time much more rapidly. 

The limb was confined by bandages for a short time, and it did not 
afterwards show any disposition to return to its unnatural position. 
The child did well, and when it began to use its legs, no difference 
could be discovered between them. 1 

J. Youmans, of Portageville, X. Y., reports a similar case which 
occurred in his own practice. A healthy woman was delivered, on the 
16th of August, 1859, of a full-grown female child, whose left knee 
was so completely dislocated that the toes rested upon the anterior part 
of the thigh near the groin. Dr. Youmans immediately took hold of 
the limb and brought it to its natural form, but as soon as he relin- 
quished his hold, it flew back to its original position. Having again 
straightened the leg it was retained in place easily by two pieces of 
whalebone tied upon each side of the thigh and body. Some soreness 
and swelling ensued, and it was some weeks before the splint could be 
safely removed. At the time of the report, October 11, 1860, the child 
was using the limb with as much freedom and dexterity as other chil- 
dren of her own age. 

In the report particular attention is called to the disposition on the 
part of the limb to resume its unnatural position with a spring, show- 
ing contraction of the anterior muscles of the thigh; to the fact that 
the patella of this knee was smaller than the other, and that the skin 
on the front of the knee was wrinkled as it is usually back of the knee 
in fat children. 2 

I have mentioned a case of congenital forward dislocation of both 
tibia? which came under my observation, in the section on congenital 
dislocations of the hip, and I have recently seen a case of congenital 
subluxation of both tibia? backwards, occasioned by contraction of the 
hamstrings. Section of the muscles restored the bones nearly to their 
normal position. 

Chatelain was consulted in relation to a similar case, in which'the 
restoration of the limb to its natural position was also easily effected, 
and by means of three metallic splints, applied during about fifteen 
days, the cure was consummated. Chatelain directed, however, that 
the leg should be kept flexed upon the thigh eight days longer. 3 

Kleeberg found a child with the leg so much flexed forwards (ex- 
tended) upon the thigh that the popliteal region became the lowest 
point of the limb; in front and above the articular extremity of the 
tibia could be felt, and the condyles of the femur made a correspond- 
ing projection behind into the popliteal space. This was plainly an 
example of complete luxation ; and, contrary to what was observed in 
Bard's case, flexion of the limb backwards was difficult and painful. 

The treatment was commenced by securing the limb in a straight 
position by means of a splint and roller ; subsequently, Kleeberg car- 
ried the limb back to an obtuse angle, and finally, it was kept eight 

1 Bard, Amer. Journ. Med. Sci., Feb. 1835, p. 555, from Bost. Med. and Surg. 
Journ., Nov. 26, 1834. 

2 Youmans, Bost. Med. and Surg. Journ., Oct. 25, 1860, vol. lxiii, p. 250. 
3 -Chatelain, Bibliotheque Med , torn, lxxv, p. 85. 



824 CONGENITAL DISLOCATIONS. 

days in a position of extreme flexion. A complete cure was said to 
have been accomplished in about two weeks. 1 

Guerin has seen a subluxation backwards, accompanied with a slight 
rotation of the head of the tibia outwards, in a girl fourteen years old; 
and which, he affirms, was congenital, characterized by a permanent 
flexion (backwards) of the leg upon the thigh, and a sliding of the con- 
dyles of the tibia backwards. 

This girl was under Guerin's treatment, but with what result is not 
stated. 2 

Chaussier found both tibise displaced backwards in an infant other- 
wise" deformed. 3 

Robert speaks of an example of lateral subluxation in a man, which 
had existed from birth. The right knee was thrown inwards, and the 
left outwards. 4 

Guerin " operated " publicly upon a child, two years old, who had a 
congenital dislocation of the head of the tibia backwards and inwards, 
accompanied with a slight rotation of the leg inwards. 5 In what man- 
ner he operated, and with what result, he does not inform us. 

The same writer speaks of a subluxation backwards and outwards, 
with rotation in the same direction, a deformity which, he affirms, is 
very frequent, and which appears especially after birth, although the 
causes which produce it have given their first impulse during intra- 
uterine life. 

The case quoted from Robert, by Malgaigne, as an example of dis- 
location inwards, seems to have been rather a case of semi-rotation of 
the articular surfaces, the inner condyle being thrown back into the 
popliteal space, while the outer condyle still retained its natural posi- 
tion. 

I 16. Congenital Dislocations of the Tarsal Bones. 

Under this general term may be included all those varieties of sub- 
luxation of the several bones which compose the tarsus, and which are 
known as examples of talipes or club-foot; such as tibio-astragaloid 
luxations, astragalo-scaphoid, calcaneo-astragaloicl, calcaneo-cuboid, etc. 

Although these deformities may properly enough claim a place in a 
chapter on congenital dislocations, they have so long been the subjects 
of special treatises as to justify their exclusion from the present volume. 

§ 17. Congenital Dislocations of the Toes. 

Observed occasionally at the metatarso-phalangeal articulations ; the 
articular facets of the first phalanges suffering a subluxation upwards, 
or laterally upon the corresponding metatarsal bones. 

Guerin has noticed especially a congenital lateral subluxation of the 
great toe. 6 



1 Kleeberg, Malgaigne, op. cit., p. 983. 2 Guerin, sur les Lux. Congen., p. 33. 
3 Chaussier, Malgaigne, op. cit., p. 884. 4 Kobert, Malg., op. cit., p. 985. 
5 Guerin, sur les Lux. Congen., p. 33. 6 Guerin, op. cit., p. 34. 



INDEX. 



PART I. FRACTURES. 



Abscess in fracture of the sternum, 173 

Acetabulum, 359 

Acromion process, 215 

Amesbury's thigh splint, 420 

Anaesthetics, use of, in diagnosis, 37 

Anatomical neck of humerus, 223 

Anaplasty in fractures of the septum narium, 

98 
Anchylosis after Colles's fracture, 295 

after fractures of elbow, 2^6 

excision for anchylosis of knee, 459 
Apparatus immobile, 54 

in fractures of the leg, 489 
Arytenoid cartilages, fractures of, 142 
Ashhurst, fracture of astragalus, 505 
Astragalus, 502 
Atlas, 167 

and axis, 168 
Axis, 164 
Ayres, compound fracture of clavicle, 191 



Badly united fracture of leg, 501 

Bartlett's apparatus for broken clavicle, 203 

Barton's bran dressing, 63, 499 

bandage for fractured jaw, 133 

trephining vertebrae, 152 

fracture of lower end of radius, 293 
Base of acetabulum, 360 
Bauer's wire splints, 498 
Beach, R. E., fracture of patella, 470 
Beans, lower jaw, 127 
Bending of bones, 74 
Biceps, displacement of long head, 614 

rupture of, 614 
Bigelow, stellate fracture of lower end of ra- 
dius, 291 

rim of acetabulum, 362 
Boardman, fracture of zygoma, 108 
Body of the scapula, 209 
Bodies of the vertebrae, 154 
Bond's elbow splint, 263 

radius splint, 298 
Bosworth, Frank, tracheotomy in fracture of 

lower jaw, 112 
Box for leg, 499 
Boyer's thigh splint, 420 
Brainard, perforator, 71 
Buck, lower jaw, 122 

thigh splint, 427 
Burge, patella, 471 



Calcaneum, 503 

Carpal bones, 343 

Cartilages, 180 

Carved splints, radius, 305 

Cervical ligaments, strains of, 160 

vertebrae, bodies of five lower, 158 

axis, 164 

atlas, 167 

atlas and axis, 168 
Children, fracture of femur, 453 
Chronic rheumatic arthritis, 385 
Clark, fracture of humerus, 250 
Clark's case of fracture of pelvis, 352 
Clavicle, 182 

partial fractures, 183 

repair of fractures, 187 
Cline, trephining vertebrae, 151 

fracture of atlas, 167 
Coates, fracture bed, 445 

bran dressings, 63 
Coccyx, 367 
Colles's fracture, 286 
Comminuted fractures, 61 
Common signs of fracture, 34 
Compound fractures, 61 

forearm, 343 

thigh, Gilbert on, 429 

thigh, author's opinion, 455 

patella, 466 

tibia and fibula, 489 
Concussion of spinal marrow, 161 
Condyles of humerus, 267 
internal, 272 
external, 275 
base, 257 
base and between condyles, 264 

of femur, 455 

external, 455 
internal, 456 
base, 458 

between condyles, 458 
Congenital, 31, 246, 473 

Cooper, Sir Astley, fracture of olecranon pro- 
cess, 329 

neck of femur within capsule, 379 

patella, 468 
Coracoid process, 219 
Coronoid process of ulna, 315 
Cotyloid cavity, 359 

Counter-extension by adhesive plaster, 429 
Cradle for leg, 498 



53 



826 



INDEX — FRACTURES. 



Crnndall, extension, fracture of leg, 495 
Cricoid cartilage, 142, 144 
Crosby, neck of femur within capsule, 389 
external condyle, 455 



Daniels's fracture-bed, 447 
Deformities of legs, 501 
Delayed or non-union, 63 

humerus, 248 

tibia, 474 
Dennis, F. S., fracture of inferior maxilla, 117 
Dextrin, 55 
Diagnosis, general, 33 
Dieffenbach. tenotomy in fracture of olecranon 

process, 331 
Dislocation of humerus, differential diagnosis, 

238 
Division of fractures, general, 27 
Dorsal vertebrae, 158 
Dorsey, fracture of patella, 467 
Dugas, sign of dislocation of humerus, 238 
Dupuytren's case of fracture of a dorsal ver- 
tebra, 158 

body of a lower cervical vertebra, 159 

dressing for fracture of fibula, 480 



Elbow splint, Physick's, 262 

Kirkbride's, 262 

Rose's, 262 

Welch's, 262 

Bond's, 263 

the author's; 264 
Else, fracture of axis, 164 
Emphysema in fracture of ribs, 178 
Epicondyle of humerus, external, 272 

internal, 268 
Epiphyseal separations, 29 

acromion, 216 

humerus, upper end, 229 
lower end, 257 

femur, upper end, 373 
lower end, 460 

trochanter major, 403 
Epiphyses, sternum, 170 

scapula, 217 

humerus, 230 

radius. 310 

ulna, 319 

os innominatum, 351 

femur, 368 

tibia, 473 

fibula, 477 
Epitrochlea, 268 
Etiology, general, 29 
Eve, non-union of ribs, 177 

patella, 466 
Exciting causes, general, 30 
Experiments on bending, 75 

on partial fractures, 80, 83 
External epicondyle of humerus, 272 

condyle of humerus, 275 
femur, 455 
Extension of thigh by adhesive plaster, 444 



Fanning, N. , humerus, 247 
Fauger, Colles's fracture, 298 
Felt splints, 51 
Femur, 367 

neck, within capsule, 369 



Femur, neck, anatomy of, George K. Smith, 
383 

differential diagnosis, 374 

without capsule, 393 

trochanter major and base of neck, 401 

epiphysis of trochanter major, 403 

shaft, 404 

measurement of, 418 

in children, 453 

external condyle, 455 

internal condyle, 456 

between condyles, 458 

base of condyles, 458 

separation of lower epiphysis, 460 
Fibula, 477 
Fingers, 347 
Fissures, 86 

neck of femur, 372 
Fitch, fracture of lower jaw, 131 
Flagg's thigh apparatus, 426 
Floating cartilages in knee-joint, 740 
Forearm, 322 

Fore's case of fracture of hyoid bone, 138 
Four-tailed bandage for broken jaw, 133 
Fracture beds, 445 

Jenks, 445 

Hewson, 445 

Barton, 445 

Coates, 445 

Daniels, 447 

Burges, 432 

Crosby, 448 
Fracture-box, 499 



Gangrene, after fracture at base of condyles 
of humerus, 261 

Dupuytren's cases after fracture of radius, 
305 

Robert Smith's cases, 307 

Norris, 308 

after fracture of forearm, 335 

leg. from tight roller, 433 

patella, 468 

from tight bandages, 48, 476 

leg, from tight bandages, 487 

from use of " apparatus immobile," 433, 
489 
Gibson, bandage for fractured jaw, 132 

fracture of clavicle, 192 

of coracoid process, 219 
Gilbert, apparatus for broken femur, 444 

leg, 495 
Glenoid cavity of scapula, comminuted, 214 
Granger, fracture of epicondyle. 268 
Greater tubercle of humerus, 227 
Gunning's interdental splint, 126 
Gunshot fractures, 510 

treatment in, 513 
Gutta-percha splints, 52 



Harris, separation of upper maxillary bones, 

103 
Harrold, lumbar vertebrae, 156 
Hartshorne, Edward, clavicle, 197 
Hartshorne, Joseph B., thigh apparatus, 428 
Hays, radial splint, 298 
Hayward, lower jaw, 123 
Head of femur, 369 

of radius, 282 

and anatomical neck of humerus, 223 



INDEX FRACTURES. 



827 



Head and neck of humerus, longitudinal frac- 
ture, 226 
Hewson, fracture-bed, 445 
Hodge, thigh splint, 430 
Hodgen's fracture-cradle, 515 

wire, suspension splint, 424 
Hodges, head of radius. 282 
Horner, thigh apparatus, 428 
Humerus, 221 

anatomical neck, 223 

head and neck, 223-227 

tubercles, 227 

longitudinal fracture of head and neck, 
227 

surgical neck, 229 

upper epiphysis, 229 

differential diagnosis, 238 

shaft, 246 

lower epiphysis, 257 

base of condyles, 257 

with splitting of condyles, 264 

condyles, 267 

internal epicondyle, 268 

external epicondyle, 272 

internal condyle, 272 

external condyle, 275 

delayed union, 276 

dislocation of, 238 
Hutchinson, leg splint, 493 

J. C, fracture of spine, 152 
Hyde, F. E., fractures of lemur, 368 
Hyoid bone, 137 



Ilium, 355 

Immovable apparatus, 54 

leg, 489 
Impacted fractures, 28 

head and neck of humerus, 223 

tubercles, 227 

neck of femur within capsule, 373 
without the capsule, 395 
Incomplete fractures, 74 
Inferior maxilla, 11 1 

Interstitial absorption of neck of femur, 385 
Internal condyle of humerus, 272 

femur, 456 
Interdental splints, 125 
Intrauterine fracture, 31, 246, 473 

fracture of tibia, 473 
Ischium, 354 



Jackson, acromion process, 216 
Jarvis's adjuster, 494 
Jenks, fracture-bed, 445 
Johnson, neck of femur, 382 



Key, lumbar vertebrae, 157 
Kingsley, fracture of lower jaw, 131 
Kirkbride, elbow splint, 262 



Larynx, fracture of, 141 

Lausdale, patella, 472 

Lente. fracture of dorsal vertebra, 158 

femur, 430 

non-union, 68 

pelvis, 350 
Lewitt. patella, 466 
Liston, thigh splint, 416 



Liston, leg splint, 497 

Lockwood, fracture of humerus at birth, 246 

Long splints. 48 

Lonsdale, extension in fracture of humerus, 24 9 

patella, 469 
Lower jaw, 111 



Malar bone, 99 

McDowell, remarkable displacement of head 
of humerus, 224 

separation of upper epiphysis, 232 
Malgaigne, apparatus for fracture of leg, 500 
Many-tailed bandage, 47 
March, acromial separations, 217 
Martin, fracture of humerus, 250 
Maxilla, superior, 102 

inferior, 111 
Measurement of thigh and leg, 418 
Metacarpus, 344 
Metatarsus, 507 
Metallic splints, 48 
Monahan, fracture of astragalus, 502 
Moore, Colles's fracture, 293 

fracture of clavicle, 200 
Morbus coxa? senilis, 385 
Morland, statistics of fracture of tibia and 

fibula, 483 
Mott, prognosis in Colles's fracture, 296 

electricity in non-union, 68 
Mussey, fracture of coracoid process, 219 
Mutter's "clamp," 126 

neck of radius, 282 



Neck of femur, 369 

within capsule, 369 

prognosis, 378 

G. K. Smith on, 383 

without capsule, 393 
Neck of humerus, anatomical, 223 

surgical neck, 229 
Neck of lower jaw, 113 
Neck of radius, 279 
Neck of scapula, 214 

signs of fracture, 238 
Neil], maxilla superior, 106 

coracoid process, 219 
thigh, 425 

leg, simple fracture, 494 

compound fracture, 494 
Nelaton, radial splint, 298 
Non-union, 63 

humerus, 252 

lower jaw, 120 

ribs, 177 
Norris, delayed and non-union, 64 

astragalus. 505 

gangrene from bandages, 308 

tibia, 476 
Nose, fracture of, 91 
Nott. wire splints. 48 

thigh apparatus, 422 



Odontoid process of axis, 164 
Olecranon process, 324 

tenotomy, 331 
Ossa nasi, 91 



Packard, J. A., clavicle, 197 



828 



INDEX — FRACTURES. 



Palmer's thigh splint, 423 
Partial fracture, 78 
Patella, 461 
Pelvis, 350 

traumatic separations, 350 
Phalanges of fingers, 347 

toes, 502 
Pubes, 350 



general considera- 



Radius, 279 

Radius and ulna, 332 

Reduction of fractures 

tions, 44 

Refracture of badly united legs, 501 
Repair of fracture, 38 
Resection for badly united fractures, 501 
Rheumatic arthritis, chronic, 385 
Rhinoplasty, 98 
Ribs, 175 

cartilages of 180 
Rim of acetabulum, 362 
Rodet, neck of femur, 371 
Rogers, trephining vertebrae, 152 
Roller, 46 
Rose, elbow splint, 262 



Sacrum, 365 

Sacroiliac symphysis, 366 

Salter's cradle for leg, 499 

Sargent, separation of upper maxillary bones, 

102 
Sayre, L. A., clavicle, 201 
Scapula, 209 

body, 209 

neck, 214 

acromion process, 215 

coracoid process, 219 

epiphyses of, 216 
Scultetus, bandage, 47 
Seineiology, general, 33 
Septum narium, 96 
Setting bones, 45 
Seutin, dressing, 54 
Shaft of humerus, 246 

radius, 283 

ulna, 311 

femur, 404 
Shoulder-joint; differential diagnosis of acci- 
dents, 238 
Shrady, radius splint, 299 
Side splints, 48 
Sling for broken jaw, 133 
Smith, E. P., radial splint, 299 
Smith, Nathan R., fracture of femur, 422 
Smith, Robert, head of humerus, 225 
Smith. Stephen, fracture of lower jaw, 119 

odontoid process of axis, 167 
Smith, George K., insertion of capsule of hip- 
joint, etc., 383 
Spinal marrow, concussion, 161 
Spinous processes : vertebrae, 146 

ilium, 355 
Splints, 48 
Starch bandage, 54 
Sternum, 169 

diastasis, 170 
Stone, base of condyles and resection, 267 
Styloid process of radius, 292 
Surgical neck of humerus, 229, 240, 242 
Swing box for leg, 498 



Symphyses of pelvis, 350 

of pubes, 351 

sacroiliac, 366 
Symphysis pubis, separation of, 351 



Tarsus, 502 

astragalus, 502 

calcaneum, 503 
Tenotomy in fractures of olecranon process, 

331 
Thompson, fracture of lumbar vertebrae, 157 
Thyroid cartilage, 141 
Thyroid and cricoid cartilages, 142 
Tibia, 472 

Tibia and fibula, 481 
Toes, 509 

Transverse processes of spine, 148 
Treatment of fractures, general, 44 
Trephining for fracture of vertebrae, 151 
Trochanter major, 401 
Trochlea of humerus, 272 
Tubercles of humerus, 227, 239, 242 



Ulna, resection of, 309 
Ulna, 311 

shaft, 311 

coronoid process, 315 

olecranon process, 324 
Upper epiphysis, humerus, 229 

femur. 373 
Upper maxillary bones, 102 



Vanderveer, fracture in utero, 33 
Vandeventer, fracture of vertebral arch, 149 
Vanwagenen's suspension apparatus, 492 
Velpeau, mode of dressing fractures with dex- 
trin and rollers, 55 
Vertebral arches, 149 
Vertebrae, 146 

spinous processes, 146 

transverse processes, 148 

vertebral arches, 149 

bodies, 154 

lumbar, 156 
dorsal, 158 
cervical, 158 

axis, 164 

atlas, 167 

atlas and axis, 168 



.49 



Warren on anchylosis at elbow-joint, 

Water-beds, 163 

Watson, fracture of lower jaw, 113 

lower epiphysis of humerus, 257 

patella, 464 
Weber, plaster of Paris bandage, 60 
Wells, internal condyle of femur, 456 
Whittaker, pelvis, 353 
Wire-beds, 164 
Wire splints, 48 

Wire rack for fracture of leg, 500 
Wood, fracture of patella, 467 
Wooden splints, 49 
Wrist, 343 



Zygomatic arch, 107 



278 



I NDEX— DIS LOCATIONS. 



829 



PAET II. DISLOCATIONS. 



Agnew, D. H., rupture of axillary vein, 599 
Anaesthetics, 532 
Ancient luxations, 526 

inferior maxilla, 536 

spine, 544 

clavicle, outer end, 566 

humerus, 593 

head of radius forwards, 622 

radius and ulna backwards, 634 

thumb, 661 

femur, 727 
Andrews, inferior maxilla, 533 
Ankle-joint. 756 
Anomalous dislocations of the hip, 719. See 

Femur. 
Anterior oblique dislocation, 721 
Astragalus, 769 
Atlas, dislocations of, 551 
Axillary artery, rupture of, 597 

vein, rupture of, 598 
Ayres, dislocation of cervical vertebra, 549 



Batchelder, head of radius, 617, 622 

thumb, 664 
Biceps, rupture or displacement of, 614 
Bigelow, H. J., on dislocations of hip, 677 
Blackman, ancient dislocations of humerus, 
597 

femur, reduced after six months, 727 
Bloxhanrs dislocation tourniquet, 691 
Brainard, reduction of ancient luxation of 
elbow, 634 



Calcaneum, dislocation of, 778 
Canton, radius and ulna forwards, 644 
Carpus, 645 

backwards, 648 

forwards. 651 

congenital, 814 
Carpal bones among themselves, 655 
Carpo-metacarpal articulation, 657 
Cartilages, of ribs from one another, 556 

in knee-joint, 754 
Caswell, dislocation of patella, 822 
Clavicle, dislocations of, 557 

sternal end forwards, 557 

sternal end upwards, 561 

sternal end backwards, 562 

acromial end upwards, 564 

acromial end downwards, 570 

under coracoid process, 57 L 

both ends, 572 

congenital, 808 
Clove-hitch, 532 
Compound pulleys, 532 
Compound dislocations of the long bones, 785 

reduction in, 791 

non-reduction in, 794 

amputation in, 794 



Compound dislocations, tenotomy in, 795 

resection in, 795 
Congenital dislocations ; general observations 
and history, 801 

general etiology, 802 

inferior maxilla, 804 

spine, 807 

pelvic bones, 808 

sternum, 808 

clavicle, 808 

shoulder, 809 

radius and ulna backwards, 812 

head of radius, 813 

wrist, 814 

fingers, 814 

hip, 815 

patella, 821 

knee, 822 

tarsus. 824 

toes, 824 
Cooper, Sir Astley, method of reducing dislo- 
cation of humerus, 589 
Coxo-femoral dislocations, 672. See Femur. 
Crosby, dislocation of thumb. 665 

ancient dislocation of elbow, 636 
Cuboid, dislocations of, 779 
Cuneiform bones, dislocation of, 780 



Damainville, statistics of dislocations of fe- 
mur, 692 
Darby, shoulder, 586 

Davis, Gr. P. .vertical dislocation of patella, 743 
Direct causes of dislocations, 527 
Dislocations, 525 

Division and nomenclature of dislocations, 525 
Double dislocation of lower jaw, 533 
Dupierris, femur reduced after six months, 727 
Dynamometer, 692 



Elbow-joint, 626 

Everted dorsal dislocation of femur, 680 
Exciting causes, general, 527 
Extension by a twisted rope, 532, 690 



Femur, dislocation of, 672 

dislocation on dorsum ilii, 674 

reduction by manipulation, 682 
reduction by extension. 688 
dislocation into great ischiatic notch, 701 
below the tendon, 703 
dislocation into foramen thyroideum, 709 
dislocation upon the pubes, 714 
anomalous dislocations of the femur, 7 1 9 
downwards and backwards upon the 

body of the ischium, 723 
downwards and backwards into lesser 

ischiatic notch, 723 
behind the tuber ischii, 723 



830 



INDEX — DISLOCATIONS. 



Femur, dislocation directly up, 719 
directly down, 724 
forwards into perineum, 725 
ancient dislocations. 727 
partial dislocations, 731 
with fracture, 732 
in children, 526, 673 
congenital, 815 
voluntary, 735 
Fenner, dislocation of femur on dorsum ilii, 

676 
Fibula, upper end forwards, 767 
backwards, 768 
lower end, 769 
"Fifth" dislocation of femur, 723 
Fingers, dislocations of first phalanx, 660, 668 
second and third, 669 
congenital, 814 
Foot, dislocation outwards, 756. See Tibia. 
Fountain, dislocation of femur uponpubes, 717 



Gazzam, rotation of patella on its inner mar- 
gin, 742 
General division, 525 

direct or exciting causes, 527 

predisposing causes, 526 

prognosis, 530 

pathology, 528 

treatment, 530 

symptoms, 527 
Gibson, ancient dislocation of humerus, 598 
Gilbert, A. W.. dislocation of lower jaw, 534 
Grant, astragalus, 776 

Graves, dislocation of dorsal vertebrae, 543 
Gunn, dislocation of thigh on dorsum ilii, 676 



Hart, dislocation of astragalus, 773 
Hartshorne, reduction of humerus by manipu- 
lation (note), 602 
Head upon the atlas, 553 

Haynes, S., double dislocation of clavicle, 572 
Hinckerman, cervical vertebrae, 548 
Hodge, statistics of dislocations of the femur, 

673 
Horner, partial dislocation of fourth cervical 

vertebrae, 546 
Howe, reduction of dislocation of the hip by 

manipulation, 685 
Humerus, dislocations of, 573 

double, 603 

downwards, 574 

forwards, 602 

fracture in reduction, 599 

backwards, 609 

partial, 613 

ancient, 593 

rupture of axillary artery and vein, 599 

with fracture, 601 

congenital, 809 
Humero-scapular dislocation, 573. See Hu- 
merus 
Hutchinson, dislocation of femur, 702 



Ilio-femoral ligament, 677 
Ilio-pubic dislocation of femur, 714 
Indian " puzzle," 666 
Inferior maxilla, 533 

double dislocation, 533 

single dislocation, 537 



Inferior congenital dislocation, 804 

Ingalls, reduction of dislocation of hip by 

manipulation, 686 
Internal derangement of knee-joint, 754 
Ischio-pubic dislocation of femur, 709 
Ischiatic dislocation of femur, 701 



Jarvis's adjuster, 532, 595, 691 



Kirkbride, dislocation of the femur upon pos- 
terior part of the body of the ischium, 723 

Knee, slipping of semilunar cartilages, 754. 
See Tibia. 

Krackowitzer, dislocation of head of radius in 
delivery, 617 



La Mothe, method of reducing dislocation of 

humerus, 588 
Lehman, spontaneous dislocation of shoulder, 

575 
Lente, fifth cervical vertebra, with fracture, 
546 
fifth cervical vertebra, without fracture, 

546 
femur directly upwards, 721 
Levis, reduction of dislocation of thumb, 665 
Ligamentum patellae, rupture of, 744 
Lister, rupture of axillary artery, 598 
Long bones, compound dislocation in, 785 
Long head of biceps, displacement of, 614 
Lower jaw, 533 

simulating luxation of, 538 
Lumbar vertebrae, 541 



Markoe, on reduction of dislocation of femur, 
687 

head of radius backwards, 623 

femur with fracture, reduced, 734 
Maxson, dislocation of cervical vertebrae, 549 
Mercer, on partial dislocations of humerus, 615 
Metacarpus, 657 

Metacarpophalangeal articulation, 660 
Metatarsus," 782 
Middle tarsal dislocation, 779 
Moore, on reduction of dislocation of femur, 
676 

ulna, 653 
Mussey, dislocation of thumb, 664 

ancient dislocation of elbow, 636 



Norris, ancient dislocations of the humerus, 
600, 605 
dislocation of humerus mistaken for a 

contusion, 605 
compound dislocation of thumb, 667 
North, N. C, double dislocation of clavicle, 
572 

Occipito-atloidean dislocations, 553 



Pardee, E. L , double dislocation of humerus, 

603 
Parker, head of humerus in subscapular 
fossa, 603 
backwards, 610 
head of radius backwards, 622 



INDEX — DISLOCATIONS. 



831 



Parker, head of radius outwards, 624 

femur into perineum, 725 
Patella, outwards, 737 

inwards, 740 

on its axis, 740 

upwards, 744 

downwards, 746 

congenital, 821 
Pathology, general, 528 
Pelvis, congenital, 808 
Pettit, A., dislocation of tibia, 750 
Phalanges, thumb and fingers, 660 

toes, 784 
Pope, dislocation of femur into perineum. 726 
Predisposing causes, general, 526 
Prognosis, general, 530 
Pseudo-luxations of inferior maxilla, 538 
Pulleys, 532 
Purple, dislocation of cervical vertebrae, 546 



Radius, head dislocated forwards, 617 

backwards, 622 

outwards, 624 

congenital, 813 
Radius and ulna, dislocation backwards, 626 

congenital, 812 

outwards, 636 

inwards, 641 

forwards, 644 
Radio-carpal articulation, 645. See Carpus. 
Radio-ulnar articulation, inferior, 652 
Rupture of quadriceps femoris, 746 
Reid, reduction of dislocation of femur by 

manipulation, 687 
Ribs from vertebrae, 553 

from sternum, 555 

one cartilage, upon another, 556 
Rochester, sternal end of clavicle upwards, 561 
Rudiger, dislocation of dorsal vertebrae, 544 



Sacro-sciatic dislocation of femur, 701 
Sanson, third cervical vertebra, 547 
Scaphoid, dislocation of, 780 
Schuck, dislocation of cervical vertebra, 547 
Shoulder, dislocation of, 573. See Humertis. 
Single dislocation of lower jaw, 537 
" Sixth " dislocation of femur, 719 
Skey, method of reducing dislocation of hu- 
merus, 591 
Smith, Nathan, on reduction of dislocation of 
the humerus, 587 
reduction of femur by manipulation, 683 
Smith H. H., on reduction of humerus, 592 
Spencer, dislocation of cervical vertebra, 547 
Spine, 540. See Vertebra. 
Squire. T. H., dislocation of radius and ulna 

inwards. 642 
Sternum, congenital dislocations, 808 
Sternberg, vertical dislocation of patella, 743 
Subcoracoid dislocation of humerus, 602 
Subclavicular dislocation of humerus, 602 
Subcotyloid dislocation of femur, 724 
Subluxation of the jaw, 538 
Subglenoid dislocation of the humerus, 574 
Subpubic dislocation of femur, 709 
Subspinous dislocation of humerus, 609 
Swan, dislocation of dorsal vertebra, 544 
Symptomatology, general. 527 



Tarsus, 769 

astragalus, 769 

astragalo-calcaneo-scaphoid, 777 
calcaneum. 778 
middle tarsal dislocation, 779 
os cuboides, 779 
os scaphoides, 780 
cuneiform bones, 780 
congenital, 824 
Tendons, dislocation of, 614, 807 
Thigh, 672. See Femur. 
Thumb, first phalanx, 660 
backwards, 660 
forwards, 667 
second phalanx, 669 
Tibia, dislocation of upper end, 745 
backwards, 746 
forwards, 748 
outwards, 750 
inwards, 752 

backwards and outwards, 752 
congenital, 822 
lower end, inwards, 756 
outwards, 761 
forwards, 762 
backwards, 766 
dislocation of lower end, 756 
Tibio-tarsal luxations, 756 
Toes, 784 

congenital, 824 
Treatment, general, 530 
Tripod for vertical extension of femur, 700 
Trowbridge, head of humerus backwards, 610 
Twisted rope, extension, 532 



Ulna, upper end backwards, 625 
lower end backwards, 652 
forwards, 289, 654 
Unilateral luxation of lower jaw, 537 



Yan Buren, W. H. , dislocation of humerus 
backwards, 610 

reduction of femur by manipulation, 696, 
712 
Varick, T. R., radius and ulna outwards, 636 
Vertebrae. 540 

lumbar, 541 

dorsal, 542 

six lower cervical, 545 

atlas upon axis, 551 

head upon atlas, 553 

congenital dislocations, 801 
Voluntary dislocations, 735 



! Warren, humerus with fracture, 601 

I Waterman, T., reduction of elbow, 632 

f Watson, dislocation of patella outwards, 739 

Wells, dislocation of tibia, 753 

Windlass for extension, 532 

Wood, dislocation of cervical vertebrae, 549 
humerus, with fracture, 603 

Wrist, 645. See Carpus. 



Y ligament, 677 

Youmans, J., congenital dislocation of knee, 
822 



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mouey or the books, and no publications but my own are supplied. Gentlemen will 
therefore in most cases find it more convenient to deal with the nearest bookseller. 

An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be for- 
warded by mail, post-paid, on receipt of ten cents. 

HENRY C. LEA. 
Nos. 706 and 708 Sansom St., Philadelphia, September, 1875. 



ADDITIONAL INDUCEMENT FOR SUBSCRIBERS TO 

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 



THREE MEDICAL JOURNALS, containing over 2000 LARaE PAGES, 

Free of Postage, for SIX D0LLAES Per Annum. 

TERMS FOR 1875: 

The American Journal of the Medical Sciences, and ] Five Dollars per annum, 
The Medical News and Library, both free of postage, J in advance. 

OR 

The American Journal of the Medical Sciences, published quar- ~] ^. -p. ,, 

terly (1150 pages per annum) , with | tolx 1Joilars 

The Medical News and Library, monthly (384 pp. per annum), and r per annum, 
The Monthly .Abstract of Medical Science (592 pages per • -, 
annum), J 

SEPAHA.TE SUBSCRIPTIONS TO 

The American Journal of the Medical Sciences, when not paid for in advance, 

Five Dollars. 
The Medical News and Library, free of postage, in advance, One Dollar. 
The Monthly Abstract of Medical Science, free of postage, in advance, Two 

Dollars and a Half. 

It is manifest that only a very wide circulation can enable so vast an amount of 
valuable practical matter to be supplied at a price so unprecedentedly low. The pub- 
lisher, therefore, has much gratification in stating that the very great favor with which 
these periodicals are regarded by the profession promises to render the enterprise - a 
permanent one, and it is with especial pleasure that he acknowledges the valuable 
assistance spontaneously rendered by so many of the old subscribers to the "Jour- 
nal/' who have kindly made known among their friends the advantages thus offered, 
and have induced them to subscribe. Relying upon a continuance of these friendly 
exertions, he hopes to be able to maintain the unexampled rates at which these works 



(For "The Obstetrical Journal," see p. 22.) 



2 Henry C. Lea's Publications — (Am. Joarn. lied. Sciences). 

are now offered, and to succeed in his endeavor te place upon the table of every 
reading practitioner in the United States the equivalent of three large octavo volumes, 
at the comparatively trifling cost of Six Dollars per annum. 

These periodicals are universally known lor their high professional standing in their 
several spheres. 

I. 

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 

Edited by ISAAC HAYS, M.D., 

is published Quarterly, on the first of January, April, July, and October. Each num- 
ber contains nearly three hundred large octavo pages, appropriately illustrated wher- 
ever necessary. It has now been issued regularly for over fifty years, during nearly 
the whole of which time it has been uud£r the control of the present editor. Through- 
out this long period, it has maintained its position in the highest rank of medical 
periodicals both at home and abroad, and has received the cordial support of the en- 
tire profession in this country. Among its Collaborators will be found a large number 
of the most distinguished names of the profession in every section of the United 
States, rendering the department devoted to 

ORIGINAL COMMUNICATIONS 

full of varied and important matter, of great interest to all practitioners. Thus, durii 
1874, articles have appeared in its pages from nearly one hundred gentlemen of the 
highest standing in the profession throughout the United States.* 

Following this is the "Review Department," containing extended and impartial 
reviews of all important new works, together with numerous elaborate " Analytical 
and Bibliographical Notices" of nearly all the medical publications of the day. 

This is followed by the " Quarterly Summary of Improvements and Discoveries 
in the Medical Sciences," classified and arranged under different heads, presenting 
a very complete digest of all that is new and interesting to the physician, abroad as 
well as at home. 

Thus/during the year 1874, the "Journal" furnished to its subscribers 85 Orig- 
inal Communications, 113 Reviews and Bibliographical Notices, and 305 articles in 
the Quarterly Summaries, making a total of about Five Hundred articles emanating 
irom the best professional minds in America and Europe. 

That the efforts thus made to maintain the high reputation of the "Journal" are 
:successful, is shown by the position accorded to it in both America and Europe as a 
national exponent of medical progress: — 

America continues to take a great place in this 
class of journals (quarterlies), at the Lead of which 
tiie great work of Dr. Hays, the American Journal 
of the Medical Sciences, still holds its ground, as our 
qautations have often proved — Dublin Med. Press 
and Circular, Jan. 31, 1S72. 

Of English periodicals the Lancet, arid of American 
the Am. Journal of the Medical Sciences, are to be 
regarded as necessities to the reading practitioner. — 
NT. Medical Gazttte, Jau. 7, 1871. 

The American Journal of the Medical Sciences 
yields to none in the amount of original and bor- 

And that it was specifically included in the award of a medal of merit to the Pub- 
lisher in the Vienna Exhibition in 1873. 

The subscription price of the " American Journal of the Medical Sciences" has 
never been raised during its long career. It is still Five Dollars per annum ; and 
when paid for in advance, the subscriber receives in addition the "Medical News and 
Library," making in all about 1500 large octavo pages per annum, free of postage. 

II. 

THE MEDICAL NEWS AND LIBRARY 

is a monthly periodical of Thirty-two large octavo pages, making 384 pages per 
annum. Its "News Department" presents the current information of the day, with 
Clinical Lectures and Hospital Gleanings; while the "Library Department" is de- 
voted to publishing standard works on the various branches of medical science, paged 

* Communications are invited from gentlemen in all parts of the country. Elaborate articles inserted 
by the Editor are paid for by the Publisher. 



rowed matter it contains, and has established for 
itself a reputation in every country where medicine 
is cultivated as a science. — Brit, and For. Med.-Chi- 
rurg. Review, April, 1S71. 

This, if not the best, is one of the best-conducted 
medical quarterlies in the English language, and the 
present number is not by any means inferior to its 
predecessors. — London Lancet, Aug. 23, 1S73. 

Almost the only one that circulates everywhere, 
all over the Union and in Europe. — London Medical 
Times, Sept. 5, 1868. 



Henry (J. Lea's Publications— (Am. Journ. Meet. Sciences). 3 

separately, so that they can be removed and bound on completion. In this manner 
subscribers have received, without expense, such works as "Watson's Practice," 
" Todd and Bowman's Physiology," " West on Children," " Malgaignr's Sur- 
gery;" &c. &c. With Jan. 1875, was commenced the publication of Dr. William 
Stokes's new work on Fever (see p. 14), rendering this a very desirable time for new 
subscriptions. 

As stated above, the subscription price of the " Medical News and Library" is 
One Dollar per annum in advance; and it is furnished without charge to all advance 
paying subscribers to the "American Journal of the Medical Sciences." 

III. 

THE MONTHLY ABSTRACT OF MEDICAL SCIENCE. 

The publication in England of Raukmg's " Half- Yearly Abstract of the Medi- 
cal Sciences" having ceased with the volume for Januaiy, 1874, its place has been 
supplied in this country by a monthly "Abstract" containing forty-eight large octavo 
pages each month, thus furnishing in the course of the year about six hundred pages, 
the same amount of matter as heretofore embraced in the Half-Yearly Abstract. 
As the discontinuance of the "Ranking" arose from the multiplication of journals 
appearing more frequently and presenting the same character of material, it has been 
thought that this plan of monthly issues will better meet the wants of subscribers, 
who will thus receive earlier intelligence of the improvements and discoveries in the 
medical sciences. The aim of the Monthly Abstract will be to present a careful 
condensation of all that is new and important in the medical journalism of the world, 
and all the prominent professional periodicals of both hemispheres will be at the dis- 
posal of the Editors. 

Subscribers desiring to bind the Abstract will receive, on application at the end 
of each year, a cloth cover, gilt lettered, for the purpose, or it will be sent free by 
mail on receipt of the postage, which, under existing laws, will be six cents. 

The subscription to the " Monthly Abstract," free of postage, is Two Dollars 
and a Half a year, in advance. 

As stated above, however, it will be supplied in conjunction with the "American 
Journal of the Medican Sciences" and the "Medical News and Library," making 
in all about Twenty-one Hundred pages per annum, the whole free of postage, for 
Six Dollars a year, in advance. 

The first volume of the "Monthly Abstract," from July to December, 1874, can 
be had by those who desire to have complete sets, if early application be made, for 
$1 50, forming a handsome octave volume of 300 pages, cloth. 

In this effort to bring so large an amount of practical information within the reach 
of every member of the profession, the publisher confidently anticipates the friendly 
aid of all who are interested in the dissemination of sound medical literature. He 
trusts, especially, that the subscribers to the "American Medical Journal" will call 
the attention of their acquaintances to the advantages thus offered, and that he will 
be sustained in the endeavor to permanently establish medical periodical literature 
on a footing of cheapness never heretofore attempted: 

PEEMIUM I0K NEW SUBSGKIBEKS TO THE " JOUKNAL." 

Any gentleman who will remit the amount for two subscriptions for 1875, one of 
which must be for a new subscriber, will receive as a premium, free by mail, a copy of 
"Flint's Essays on Conservative Medicine" (for advertisement of which see p. 15), 
or of •' Sturges's Clinical Medicine" (see p. 14), or of the new edition of "Swayne's 
Obstetric Aphorisms" (see p. 24), or of "Tanner's Clinical Manual" (see p. 5), 
or of "Chambers's Restorative Medicine" (see p. 16), or of "West on Nervous 
Disorders of Children" (see page 21). 

%* Gentlemen desiring to avail themselves of the advantages thus offered will do 
well to forward their subscriptions at an early day, in order to insure the receipt of 
complete sets for the year 1875, as the constant increase in the subscription list 
almost always exhausts the quantity printed shortly after publication. 

^gg" The safest mode of remittance is by bank check or postal money order, drawn 
to the order of the undersigned. Where these are not accessible, remittances for the 
"Journal" may be made at the risk of the publisher, by forwarding in registered 
letters. Address, 

HENRY C. LEA, 
Nos. 706 and 708 Sansom St., Philadelphia, Pa. 



Henry C. Lea's Publications — {Dictionaries). 



JJUNGLISON {ROBLEF), M.D., 

Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Con- 
taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae for 
Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes ; so as to constitute a French as well a8 
English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- 
some royal octavo volume of over 1100 pages. Cloth, $6 50; leather, raised bands, $7 50. 
(Just Issued.) 

The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terras, but to afford, under each, a condensed view of its various medical relation?, 
and thus to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the position 
of a recognized and standard authority wherever the language is spoken. 

Special pains have been taken in the preparation of the present edition to maintain this en- 
viable reputation. During the tfn years which have elapsed since the last revision, the additions 
to the nomenclature of the medical sciences have been greater than perhaps in any similar period 
of the past, and up to the time of his death the author labored assiduously to incorporate every- 
thing requiring the attention of the student or practitioner. Since then, the editor has been 
equally industrious, so that the additions to the vocabulary are more numerous than in any pre- 
vious revision. Especial attention has been bestowed on the accentuation, which will be found 
marked on every word. The typographical arrangement has been much improved, rendering 
reference much more easy, and every care has been taken with the mechanical execution. The 
work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
the additions have been incorporated with an increase of but little over a hundred pages, and 
the volume now contains the matter of at least four ordinary octavos. 

A took -well known to our readers, and of which 
every American ought to be proud. When the learned 
author of the work passed away, probably all of us 
feared lest the book should not maintain its place 
iL the advancing science whose terms it defines. For- 
tunately, Dr. Richard J. Dunglison, having assisted his 
father in the revision of several editions of the work, 



and Laving been, therefore, trained in the methods and 
iiiilued with the spirit of the book, has been able to 
edit it, not in the patchwork manner so dear to the 
heart of book editors, so repulsive to the taste of intel- 
ligent book readers, but to edit it as a work of the kind 
should be edited — to carry it on steadily, without jar 
or interruption, along the grooves of thought it has 
travelled during its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and car- 
ried through, it is only necessary to state that more 
than six thousand new subjects have been added in the 
pier en t edition. Without occupying more space with the 
theme, we congratulate the editor on the successful 
completion of his labors, and hope he may reap the well- 
earned reward of profit and honor.— Phila. Med. Times, 
Jan 3,1874. 

About the first book purchased by the medical stu- 
dent is the Medical Dictionary. The lexicon explana- 
tory of technical terms is simply a sive qua non. In a 
science so extensive, and with such collaterals as medi- 
cine, it is as much a necessity also to the practising 
physician. To meet the wants of students and most 
physi'ians, the dictionary must be condensed while 
comprehensive, and practical while perspicacious. It 
was because Dunglison's met these indications that it 
became at once the dictionary of general use wherever 
medicine was studied in the English language. In no 
former revision have the alterations and additions been 
so gveat. More than six thousand new subjects and terms 
have been added. The chief terms have been set in black 
letter, while the derivatives follow in small caps; an 
arrangement which greatly facilitates reference. We 
may safely confirm the hope ventured by the editor 
'• that the work, which possesses for him a filial as well 
a- an individual interest, will be found worthy a con- 
tinuance of the position so long accorded to it as a 
standard authority."— Cincinnati Clinic, Jan, 10, 1874. 



We are glad to see a new edition of this invaluable 
work, and to rind that it has been so thoroughly revised, 
and so greatly improved. The dictionary, in its pre- 
sent form, is a medical library in itself, and one of 
which every physician should be possessed. — iV. Y. Med. 
Journal, Feb. 1874. 

With a history of forty years of unexampled success 
and universal indorsement by the medical profession of 
the western continent, it would be presumption in any 
living medical American to essay its review. No re- 
viewer, however able, can add to its fame; no captious 
critic, however caustic, can remove a. single stone from 
its firm and enduring foundation. It is destined, as a 
colossal monument, to perpetuate the solid and richly 
deserved famine of Robley Dunglison to coming genera- 
tions. The large additions made to the vocabulary, we 
think, will be welcomed by the profession as supplying 
the want of a lexicon fully up with the march of sci- 
ence, which has been increasingly felt for some years 
past. The accentuation of terms is very complete, and, 
as far as we have been able to examine it, very excel- 
lent. We hope it may be the means of securing greater 
uniformity of pronunciation among medical men. — At- 
lanta Med. and Surg. Journ., Feb. 1874. 

It would be mere waste of words in us to express 
our admiration of a work which is so universally 
and deservedly appreciated. The most admirable 
work of its kind in the English language. — Glasgow 
Medical Journal, January, 1866. 

A work to which there is no equal in the English 
language. — Edinburgh Medical Journal. 

Few works of the class exhibit a grander monument 
of patient research and of scientific lore. The extent 
of the sale of this lexicon is sufficient to testify to its 
usefulness, and to the great service conferred by Dr. 
Robley Dunglison on the profession, and indeed on 
sthers, by its issue.— London Lancet, May 13, 1865. 

It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent of 
references. — London Medical Gazette. 



TJOBLYN {RICHARD D.), M.D. 

A DICTIONARY OF THE TERMS USED IN MEDICINE AND 

THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, 
M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 
12mo. volume of over 500 double-columned pages; cloth, $1 50 ; leather, $2 00. 
It is the best book of definitions we have, and ought always to be upon the ■indent's table. —Southern 
Med. and Surg. Journal. 



Henry 0. Lea's Publications — (Manuals). 



KTEILL {JOHN), M.I)., and &MITH {FRANCIS G.), M.D., 

Prof, of the Institutes of Medicine in the Univ. of Penna. 

AN ANALYTICAL COMPENDIUM OF THE VAPvIOUS 

BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 12mo. 
volume, of about one thousand pages, with 374 wood cuts, cloth, $4; strongly bound in 
leather, with raised bands, $4 75. 



The Coiupend of Drs. Neill and Smith is incompara- 
bly the most valuable work of its class ever published 
in this country. Attempts have been made in various 
Quarters to squeeze Anatomy, Physiology, Surgery, 
the Practice of Medicine, Obstetrics, Materia Medica, 
ind Chemistry into a single manual; but the opera- 
tion has signally failed in the hands of all up to the 
! of " Neill and Smith's' ' volume, which is quite 
a 'mracle of success. The outlines of the whole are 
admirably drawn and illustrated, and the authors 
are eminently entitled to the grateful consideration 
indent of every class. — N. 0. Med. and Surg. 
Journal. 

There are but few students or practitioners of me- 
dicine unacquainted with the former editions of this 
iiiag though highly instructive work. The 
:ience of medicine appears to have been sifted, 
s,s the gold-bearing sands of El Dorado, and the pre- 



cious factstreasuredup in this little volume. A com- 
plete portable library so condensed that the student 
may make it his constant pocket companion. — West- 
ern Lancet. 

In the rapid course of lectures, where work for the 
students is heavy, and review necessary for an exa- 
mination, a compend is not only valuable, but it is 
almost a sine qua non. The one before us is, in most 
of the divisions, the most unexceptionable of all books 
of the kind that we know of. Of course it is useless 
for us to recommend it to all last course students, but 
there is a class to whom we very sincerely commend 

tnis cheap book as worth its weight in silver that 

class is the graduates in medicine of more than ten 
years' standing, who have not studied medicine 
since. They will perhaps find out from it that the 
science is not exactly now what it was when they 
left it off.— The Stethoscope. 



ARTSRORNE {HENRY), M. D., 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology. Chemistry, Materia Medica, Practical Medicine, 
Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large 
royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on 
wood. Cloth, $4 25 ; leather, $5 00. {Lately Issued.) 
The favor with which this work has been received has stimulated the author in its revision to 
render it in every way fitted to meet the wants of the student, or of the practitioner desirous to 
refresh his acquaintance with the various departments of medical science. The various sections have 
been brought up to a level with the existing knowledge of the day, while preserving the condensa- 
tion of form by which so vast an accumulation of facts have been brought within so narrow a 
compass. The series of illustrations has been much improved, while by the use of a smaller type 
the additions have been incorporated without increasing unduly the size of the volume. 

The work before us has already successfully assert- | and the clear and instructive illustrations in some 



ed its claim to the confidence aud favor of the profe 
sion ; it but remains for us to say that in the present 
edition the whole work has been fully overhauled 
and brought up to the present status of the science. — 
Atlanta Med. and Surg. Journal, Sept. 1S7-L 

The work is intended as an aid to the medical stu- 
dent, and as such appears to admirably fulfil its ob- 
ject by its excellent arrangement, the full compilatiou 
of facts, the perspicuity a^d terseness of language, 



parts of the work.. —American Journ. of Pharmacy, 
Philadelphia, July, 1874. 

The volume will be found useful, not only to stu- 
dents, but to many others who may desire to refresh 
their memories with the smallest possible expendi- 
ture of time.— N. T. Med. Journal, Sept. 1S74. 

The student will find this the most convenient and 
useful boot of the kind on which he can lav his 
hand.— Pacific Med. and Surg. Journ., Aug. 1S74. 



\.D. 



J UDLOW {J.L.), 

A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
12mo. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit- 
able for the ofiice examination of students, and for those preparing for graduation. 



fPANNER {THOMAS HAWKES), M.D., §-c. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 

NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 
&c. In one neat volume small l2mo., of about 375 pages, cloth, $1 50. 
*%* By reference to the " Prospectus of Journal" on page 3, it will be seen that this work is 

offered as a premium for procuring new subscribers to the "American Journal of the Medical 

Sciences." 

The objections commonly, and justly, urged against 
the general run of "compends," "conspectuses," and 
other aids to indolence, are not applicable to this little 
volume, which contains in concise phrase just those 
practical details that are of most use in daily diag- 
nosis, but which the young practitioner finds it diffi- 
cult to carry always in his memory without some 
quickly accessible means of reference. Altogether, 
the book is one which we can heartily commend to 
those who have not opportunity for extensive read- 
ing, or who, having read much, still wish an occa- 
sional practical reminder.— A V. Y. Med. Gazette, Not. 
10 1870. 



Taken as a whole, it is the most compact vade me- 
cum for the use of the advanced student and junior 
practitioner with which we are acquainted. — Boston 
Med. and Surg. Journal, Sept. 22, 1870. 

It contains so much that is valuable, presented in 
so attractive a form, that it can hardly be spared 
even iu the presence of more full and complete works. 
Its convenient size makes it a valuable companion 
to the country practitioner, and if constantly car- 
ried by him, would often render him good service, 
and relieve many a doubt and perplexity. — Leaven- 
worth Med. Herald, July, 1870. 



6 Henry C. Lea's Publications — (Anatomy). 

QRAY {HENRY), F.R.S., 

Lecturer on Anatomy at St. George's Hospital, London. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 

H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Disseo- 
tions jointly by the Author and Dr. Carter. A new American, from the fifth enlarged 
and improved London edition. In one magnificent imperial octavo volume, of nearly 90C 
pages, with 465 large and elaborate engravings on wood. Price in cloth, $6 00 ; lea- 
ther, raised bands, $7 00. (Just Issued.) 
The author has endeavored in this work to cover a more extended range of subjects than is cus- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner. The- en 
gravings form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with 
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
essential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Notwithstanding the enlargement of this edition, it has been kept at its former very moderate 
price, rendering it one of the cheapest works now before the profession. 



The illustrations are beautifully executed, and ren- 
der this work an indispensable adjunct to the library 
of the surgeon. This remark applies with great force 
to those surgeons practising at a distance from our 
large cities, as the opportunity of refreshing their 
memory by actual dissection is not always attain- 
able. — Canada Med. Journal, Aug. 1870. 

The work is too well known and appreciated by the 
profession to need any comment. No medical man 
can afford to be without it, if its only merit were to 
serve as a reminder of that which s'o soon becomes 
forgotten, when not called into frequent use, viz., the 
relations and names of the complex organism of the 
human body. The present edition is much improved. 
—California Med. Gazette, July, 1870. 

Gray's Anatomy has been so long the standard of 
perfection with every student of anatomy, that we 
need do no more than call attention to the improve- 
ment in the present edition.— Detroit Review of Med. 
and Pharm., Aug. 1870. 



From time to time, as successive editions have ap- 
peared, we have had much pleasure in expressing 
the general judgment of the wonderful excellence of 
Gray's Anatomy. — Cincinnati Lancet, July, 1870. 

Altogether, it is unquestionably the most complete 
and serviceable text-book in anatomy that has ever 
been presented to the student, and forms a striking 
contrast to the dry and perplexing volumes on the 
same subject through which their predecessors strug- 
gled in days gone by. — N. T. Med. Record, June 15, 
1870. 

To commend Gray's Anatomy to the medical pro- 
fession is almost as much a work of supererogation, 
as it would be to give a favorable notice of the Biblo 
in the religious press. To say that it is the most 
complete and conveniently arranged text-book of its 
kind, is to repeat what each generation of students 
has learned as a tradition of the elders, and verified, 
by personal experience. — N T. Med. Gazette, Dec. 
17, 1870. 



&MITH [HENRY H.), M.D., and JJORNER { WILLIAM E.), M.D., 

Prof, of Surgery in the Univ. ofPenna., &c. Late Prof, of Anatomy in the Univ. ofPenna., Ac. 

AN ANATOMICAL ATLAS, illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 

fifty beautiful figures. $4 50. 
The plan of this Atlas, which renders it so peca- I the kind that has yet appeared; and we must add, 
liarly convenient for the student, and its superb ar- | the very beautiful manner in which it is "got up," 
tistical execution, have been already pointed out. We j is so creditable to the country as to be flattering to 
must congratulate the student upon the completion our national pride.— American MedicalJournal. 
of this Atlas, as it is the most convenient work of I 

HARPEY { WITJjIAM), M.D., and Q VAIN {JONES fr RICHARD). 
HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph 

Leidt, M.D., Professor of Anatomy in the University of Pennsylvania. Complete in two 
large octavo volumes, of about 1300 pages, with 511 illustrations; cloth, $6 00. 
The very low price of this standard work, and its completeness in all departments of the subject, 
ahould command for it a place in the library of all anatomical students. 



S 



fro DOES {RICHARD M.), M.D., 

Late Demonstrator of Anatomy in the Medical Department of Harvard University. 

PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In 

one neat royal 12mo. volume, half-bound, $2 00. 
The object of this work is to present to the anatomical student a clear and concise description 
of that which he is expected to observe in an ordinary couise of dissections. The author has 
endeavored to omit unnecessary details, and to present the subje3t in the form which many years' 
experience has shown him to be the most convenient and intelligible to the student. In the 
revision of the present edition, he has sedulously labored to render the volume more worthy of 
the favor with which it has heretofore been received. 



HOENER'S SPECIAL ANATOMY AND HISTOLOGY. | In 2 vols. 8vo., of over 1000 pages, with more than 
Eighth edition, extensively revised and modified. I 300 wood-cuts; cloth, $6 00. 



Henry C. Lea's Publications — (Anatomy). 



JJ7ILS0N {ERASMUS), F.R.S. 

A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 

by W.H. Gobrecht, M.D., Professor of General and Surgical Anatomy in the Medical Col- 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
one large and handsome octavo volume, of over 600 large pages; cloth, $4 00; leather, 
$5 00. 
The publisher trusts that the well-earned reputation of this long-established favorite will be 
jsiore than maintained by the present edition. Besides a very thorough revision by the author, it 
has been most carefully examined by the editor, and the efforts of both have been directed to in- 
troducing everything which increased experience in its use has suggested as desirable to render it 
a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- 
tomy. The amount of additions which it has thus received may be estimated from the fact that 
th« present edition contains over one-fourth more matter than the last, rendering a smaller type 
and an enlarged page requisite to keep the volume within a convenient size. The author has not 
only thus added largely to the work, but he has also made alterations throughout, wherever there 
appeared the opportunity of improving the arrangement or style, so as to present every fact in its 
most appropriate manner, and to render the whole as clear and intelligible as possible. The editor 
has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased 
the number of illustrations, of which there are about one hundred and fifty more in this edition 
than in the last, thus bringing distinctly before the eye of the student everything of interest or 
importance. 



II 



EATR {CHRISTOPHER), F.R. C.S., 

Teacher of Operative Surgery in University College, London. 

PRACTICAL ANATOMY: A Manual of Dissections. From the 

Second revised and improved London edition. Edited, with additions, by W. W. Keen, 
M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 
In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Cloth. $3 50 ; 
leather, $4 00. {Lately Published.) 



Pi 



Keen, the American editor of this work, in his 
preface, says: "In presenting this American edition 
of "Heath's Practical Anatomy,' I feel that I have 
been instrumental in supplying a want long felt for 
a real dissector's manual," and this assertion of its 
editor we deem is fully justified, after an examina- 
tion of its contents, for it is really an excellent work. 
Indeed, we do not hesitate to say, the best of its class 
with which we are acquainted ; resembling Wilson 
in terse and clear description, excelling most of the 
so-called practical anatomical dissectors in the scope 
of the subject and practical selected matter. . . . 
In reading this work, one is forcibly impressed with 
the great pains the author takes to impress the sub- 
ject upon the mind of the student. He is full of rare 
and pleasing little devices to aid memory in main- 



taining its hold upon the slippery slopes of anatomy. 

-St. Louis Med. and Surg. Journal, Mar. 10, 1S71. 
It appears to us certain that, as a guide in dissec- 

ion, and as a work containing facts of anatomy in 
brief and easily understood form, this manual is 
complete. This work contains, also, very perfect 
illustrations of parts which can thus be more easily 
mderstood and studied; in this respect it compares 
'avorably with works of much greater pretension. 
Such manuals of anatomy are always favorite works 
with medical students. We would earnestly recom- 
mend this one to their attention; it has excellences 
which make it valuable as a guide in dissecting, as 
well as in studying anatomy. — Buffalo Medical and 
Surgical Journal, Jan. 1871. 



F.R.G.S. 



JDELLAMY {E, 

THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text 

Book for Students preparing for their Pass Examination. With engravings on wood 
ono handsome royal 12mo. volume. Cloth, $2 25. {Just Issued.) 

We welcome Mr. Bellamy's work, as a contribu- We cannot too highly recommend it. — Student 
tion to the study of regional anatomy, of equal value 
to the student and the surgeon. It is written in a 
clear and concise style, and its practical suggestions 
add largely to the interest attaching to its technical 
details — Chicago Med. Examiner, March 1, 1S74. 

We cordially congratulate Mr. Bellamy upon hav- 
ing produced it. — Med,. Times and Gaz. 



In 



Journal. 

Mr. Bellamy has spared no pains to produce a real- 
ly reliable student's guide to surgical anatomy — one 
which all candidates for surgical degrees may con- 
sult with advantage, and which posseses much ori- 
ginal matter — Med. Press and Circular. 



M. 



AGLISE {JOSEPH). 

SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one 

volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best 
style and beautifully colored, containing 190 figures, many of them the size of life ; together 
with copious explanatory letter-press. Strongly and handsomely bound in cloth. Price 
$14 00. 

jions have hitherto, we think, been given. While 
the operator is shown every vessel and nerve where 
in operation is contemplated, the exact anatomist is 
refreshed by those clear and distinct dissections, 
which every one must appreciate who has a particle 
of enthusiasm. The English medical press has quite 
exhausted the words of praise, in recommending this 
admirable treatise. — Boston Med. and Surg. Journ. 



We know of no work on surgical anatomy which 
#an compete with it. — Lancet. 

The work of Maclise on surgical anatomy is of the 
highest value. In some respects it is the best publi- 
cation of its kind we have seen, and is, worthy of a 
place in the library of any medical man, while the 
student could scarcely make a better investment than 
this. — The Western Journal of Medicine and Surgery. 

No such lithographic illustrations of surgical re- 



fJARTSHORNE {HENRY) , M.D., 

-*■-*■ Professor of Hygiene, etc , in the Univ. ofPenna. 

HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second Edi- 

tion, revised. In <me ro.yal 12mo. volume, with 220 wood-cuts j cloth, $1 75. {Just Issued.) 



8 



Henry C. Lea's Publications — (Physiology). 



MARSHALL (JOHN), F. R. S., 

J.ZM. Professor of Surgery in University College, London, &e. 

OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. 

With Additions by Fkancis Gurnet Smith, M. D., Professor of the Institutes of Medi- 
cine in the University of Pennsylvania, Ac. With numerous illustrations. In one largo 
and handsome octavo volume, of 1026 pages, cloth, $6 50 ; leather, raised bands, $7 50. 
Id fact, in every respect, Mr. Marshall has present- j tive, with which we are acquainted. To speak of 

this work in the terms ordinarily used on such occa- 
sions would not be agreeable to ourselves, and would 
fail to do justice to its author. To write such a book 
requires a varied and wide range of knowledge, con- 
siderable power of analysis, correct judgment, skill 
in arrangement, and conscientious spirit. — London 
Lancet, Feb. 22, 1868. 

There arefew, if any, more accomplished anatomists 
and physiologists than the distinguished professor of 
surgery at University College ; and he has long en- 
joyed the highest reputation as a teacher of physiol- 
ogy, possessingremarkable powers of clearexposition 
We may now congratulate him on having com- \ and graphic illustration. We have rarely the plea- 
pleted the latest as well as the best summary of mod- I sure of being able to recommend a text-book so unre- 
em physiological science, both human and compara- ' servedlyasthis.— British Med. Journal, Jar. 25,186;" 



ed us with a most complete, reliable, and scientific 
work, and we feel that it is worthy our warmest 
commendation. — St. Louis Med. Reporter, Jan. 1869. 

We doubt if there is in the English language any 
compend of physiology more useful to the student 
than this work.— St. Louis Med. and Surg. Journal, 
Jan. 1869. 

It quite fulfils, in our opinion, the author's design j 
of making it truly educational iu its character — which 
is, perhaps, the highest commendation that can be ! 
asked. — Am. Journ. Med. Sciences, Jan. 1869. 



» 



flARPENTER (WILLIAM B.), M.D., F.R.S., 

vy Examiner in Physiology and Comparative Anatomy in the University of London. 

PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- 
cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new 
American from the last and revised London edition. With nearly three hundred illustrations. 
Edited, with additions, by Francis Gurnet Smith, M. D., Professor of the Institutes of 
Medicine in the University of Pennsylvania, Ac. In one very large and beautiful octavo 
volume, of about 900 large pages, handsomely printed; cloth, $5 50 ; leather, raised bands, 
$6 50. 

We doubt not it is destined to retain a strong hold 
on public favor, and remain the favorite text-book ivt 
our colleges. — Virginia Medical Journal. 

The above is the title of what is emphatically the 
great work on physiology ; and we are conscious that 
it would be a useless effort to attempt to add any- 
thing to the reputation of this invaluable work, and 
can only say to all with whom our opinion has any 
influence, that it is our authority. — Atlanta Med. 
Journal. 



With Dr. Smith, we confidently believe "that the 
present will more than sustain the enviable reputa- 
tion already attained by former editions, of being 
one of the fullest and most complete treatises on the 
subject in the English language." We know of none 
from the pages of which a satisfactory knowledge of 
the physiology of the human organism can be as well 
obtained, none better adapted for the use of such as 
take up the study of physiology in its reference to 
the institutes and practice of medicine. — Am. Jour. 
Med. Sciences. 



IDF THE SAME AUTHOR. 

PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Amen- 

can, from the Fourth and Revised London Edition. In one large and handsome octavo 
volume, with over three hundred beautiful illustrations. Pp.752. Cloth, $5 00. 
As a complete and condensed treatise on its extended and important subject, this work becomes 
a necessity to students of natural science, while the very low price at which it is offered places it 
within the reach of all. 



JT'IRKES (WILLIAM SENROUSE), M.D. 

A MANUAL OF PHYSIOLOGY. Edited by W. Morrant Baker, 

M.D., F.R.C.S. A new American from the eighth and improved London edition. With 
about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- 
ume. Cloth, $3 25; leather, $3 75. {Lately Issued.) 
Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book, 
presenting within a narrow compass all that is important for the student. The rapidity with 
which successive editions have followed each other in England has enabled the editor to keep it 
thoroughly on a level with the changes and new discoveries made in the science, and the eighth 
edition, of which the present is a reprint, has appeared so recently that it may be regarded as 
the latest accessible exposition of the subject. 



On the whole, there is very little in the book 
which either the student or practitioner willnotfind 
of practical value and consistent with our present 
knowledge of this rapidly changing science ; and we 
have no hesitation in expressing our opinion that 
this eighth edition is one of the best handbooks on 
physiology which we have in our language. — N. ¥. 
Med. Record, April 15, 1873. 

This volume might well be used to replace many 
of the physiological text-books in use in this coun- 
try. It represents more accurately than the works 
of Dalton or Flint, the present state of our knowl- 
edge of most physiological questions, while it is 
much less bulky and far more readable than the lar- 



ger text-books of Carpenter or Marshall. The book 
is admirably adapted to be placed in the hands of 
students. — Boston Med. and Surg. Journ., April 10, 
1873. 

In its enlarged form it is, in our opinion, still the 
best book on physiology, most useful to the student. 
—Phila. Med. Times, Aug. 30, 1873. 

This is undoubtedly the best work for students of 
physiology extant. — Cincinnati Med. News, Sept. '73. 

It more nearly represents the present condition of 
physiology than any other text-book on the subject. — 
Detroit Rev. of Med. Pharm., Nov. 1873. 



Henry C. Lea's Publications— (Physiology). 



fkALTON {J. C), M. D., 

-AS Professor of Physiology in the College of Physicians and Surgeons, New York, &e. 

A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 

of Students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- 
ume, of over 800 pages. {Nearly Ready.) 

From the Freface to the Sixth Edition. 

In the present edition of this book, while every part has received a careful revision, the ori- 
ginal plan of arrangement has been changed only so far as was necessary for the introduction of 
new material. Although the whole field of physiology has been cultivated, of late years, with 
unusual industry and success, perhaps the most important advances have been made in the two 
departments of Physiological Chemistry and the Nervous System. The number and classification 
of the proximate principles, more especially, and their relation to each other in the process of 
nutrition, have become, in many respects, better understood than formerly: though it is evident 
that this fundamental part of physiology is to receive, in the future, modifications and additions 
of the most valuable kind. 

The additions and alterations in the text, requisite to present concisely the growth of positive 
physiological knowledge, have resulted in spite of the author's earnest efforts at condensation, 
in an increase of fully fifty per cent, in the matter of the work. A change, however, in the ty- 
pographical arrangement has accommodated these additions without undue enlargement in the 
bulk of the volume. 

The new chemical notation and nomenclature are introduced into the present edition, as hav- 
ing now so generally taken the place of the old, that no confusion need result from the change. 
The centigrade system of measurements for length, volume, and weight, is also adopted, these 
measurements being at present almost universally employed in original physiological investiga- 
tions and their published accounts. Temperatures are given in degrees of the centigrade s ale, 
usually accompanied by the corresponding degrees of Fahrenheit's scale, inclosed in brackets. 
New York, September, 1875. 

A few notices of the previous edition are subjoined. 



The fifth edition of this truly valuable work on 
Human Physiology comes to us with many valuable 
improvements and additions. As a text-book of 
physiology the work of Prof. Dalton has long been 
well known as one of the best which could be placed 
In the hands of student or practitioner. Prof. Dalton 
has, in the several editions of his work heretofore 
published, labored tokeep step with the advancement 
in science, and the last edition shows by its improve- 
ments on former ones that he is determined to main- 
tain the high standard of his work. We predict for 
the present edition increased favor, though this work 
has long been the favorite standard. — Buffalo Med. 
and Surg. Journal, April, 1872. 

An extended notice of a work so generally and fa- 
vorably known as this is unnecessary. It is justly 
regarded as one of the most valuable text-books on 
'he subject in the English language. — St. Louis Med. 
Archives, May, 1872. 

We know no treatise in physiology so clear, com- 
plete, well assimilated, and perfectly digested, as 
Dalton's. He never writes cloudily or dubiously, or 
in mere quotation. He assimilates all his material, 
and from it constructs a homogeneous transparent 



irgument, which is always honest and well informed, 
\nd hides neither truth, ignorance, nor doubt, so far 
is either belongs to the subject in hand. — Brit. Med. 
Journal, March 23, 1872. 

Dr. Dalton's treatise is well known, and by many 
highly esteemed in this country. It is, indeed, a good 
elementary treatise on the subject it professes to 
teach, and may safely be put into the hands of Eng- 
lish students. It has one great merit—it is clear, and, 
on the whole, admirably illustrated. The part we 
have always esteemed most highly is that relating 
to Embryology. The diagrams given of the various 
stages of development give a clearer view of the sub- 
ject than do those in general use in this country ; and 
the text may be said to be, upon the whole, equally 
clear. — London Med. Times and Gazette, March 23, 
1872. 

Professor Dalton is regarded j ustly as the authority 
in this country on physiological subjects, and the 
fifth edition of his valuable work fully j ustifies the 
exalted opinion the medical world has of his labors. 
This last editionisgreatly enlarged. — Virginia Clin- 
ical Record, April, 1872. 



T)UNGLISON {ROBLEY), M.D., 

•*-* Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 

extensively modified and enlarged, with five hundred and thirty-two illustrations. In two 
large and handsomely printed octavo volumes of about 1500 pages, cloth, $7 00. 



TERM ANN (C. G.). 

PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- 
tion by George E. Day, M. D., F. R. S., &c, edited by R. B. Rogers, M. D., Professor of 
Chemistry in the Medical Department of the University of Pennsylvania, with illustrations 
selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- 
plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two 
hundred illustrations, cloth, $6 00. 

73 F THE SAME AUTHOR. 

MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the 

German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory 
Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- 
vania. With illustrations on wood. In one very handsome octavo volume of 336 pages, 
oloth, $2 25. 



10 



Henry C. Lea's Publications — {Chemistry). 



ATTFIELD (JOHN), Ph.D., 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, &c. 

CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL ; 

including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. Fifth Edition, revised 
by the author. In one handsome royal 12mo. volume; cloth, $2 75; leather, $3 25. 
{Lately Issued.) 

engaged in medicine and pharmacy, and we heartily 
commend it to our readers. — Canada Lancet, Oct. 
1871. 



No other American publication with which we are 
acquainted covers the same ground, or does it so well. 
In addition to an admirable expose" of the facts and 
principles of general elementary chemistry, the au- 
thor has presented us with a condensed massof prac- 
tical matter, just such as the medical student and 
practitioner needs. — Cincinnati Lancet, Mar. 1874. 

We commend the work heartily as one of the best 
text-books extant for the medical student. — Detroit 
Rev. of Med. and Pharm., Feb. 1S72. 

Th e best work of the kind in the English language. 
— N. T. PsychologicalJournal, Jan. 1872. 

The work is constructed with direct reference to 
the wants of medical and pharmaceutical students ; 
and, although an English work, the points of differ- 
ence between the British and United States Pharma- 
copoeias are indicated, making it as useful here as in 
England. Altogether, the book is one we can heart- 
ily recommend to practitioners as well as students. 
—N. Y. Med. Journal, Dec. 1871. 

It differs from other text-books in the following 
particulars: first, in the exclusion of matter relating 
to compounds which, at present, are only of interest 
to the scientific chemist ; secondly, in containing the 
chemistry of every substance recognized officially or 
in general, as a remedial agent. It will be found a 
most valuable book for pupils, assistants, and others 



When the original English edition of thiswork was 
published, we had occasion to express our high ap- 
preciation of its worth, and also to review, in con- 
siderable detail, the main features of the book. As 
the arrangement of subjects, and the main part of 
the text of the present edition are similar to the for- 
mer publication, it will be needless for us to go over 
the ground a second time ; we may, however, call at- 
tention to a marked advantage possessed by the Ame- 
rican work— we allude to the introduction of the 
chemistry of the preparations of the United States 
Pharmacopoeia, as well as that relating to the British 
authority. — Canadian Pharmaceutical Journal, 
Nov. 1871. 

Chemistry has borne the name of being a hard sub- 
ject to master by the student of medicine, and 
chiefly because so much of it consists of compounds 
only of interest to the scientific chemist ; in thiswork 
such portions are modified or altogether left out, and 
in the arrangement of the subject matter of the work, 
practical utility is sought after, and we think fully 
attained. We commend it for its clearness and order 
to both teacher and pupil. — Oregon Med. and Surg. 
Reporter, Oct. 1871. 



F 



OWNES {GEORGE), Ph.D. 



A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. With one hundred and ninety-seven illustrations. A new American, from the 
tenth and revised London edition. Edited by Robert Bridges, M. D. In one large 
royal 12mo. volume, of ahout 850 pp., cloth, $2 75 j leather, $3 25. (Lately Issued.) 
This work is so well known that it seems almost] other work that has greater claims on the physician, 
superfluous for us to speak about it. It has been a ; pharmaceutist, or student, than this. We cheerfully 
favorite text-book with medical students for years, j recommend it as the best text-book on elementary 
and its popularity has in no respect diminished. | chemistry, and bespeak for it the careful attention 
Whenever we have been consulted by medical stu- ; f students of pharmacy.— Chicago Pharmacist, Aug. 
dents, as has frequently occurred, what treatise on 1869. 
chemistry they should procure, we have always re- 
commended Fownes', for we regarded it as the best. Here is a new edition which has been long watched 
There is no work that combines so many excellen- 1 for by eager teachers of chemistry. In its new garb, 
ces. It is of convenient size, not prolix, of plain! and under the editorship of Mr. Watts, it has resumed 
perspicuous diction, contains all the most recent j its old place as the most successful of text-books.— 
discoveries, and is of moderate price.— Cincinnati^ Indian Medical Gazette, Jan. 1, 1869 
Med. Repertory, Aug. 1869. It wm continue, as heretofore, to hold the first ran* 

Large additions have been made, especially in the ! is a text-book for students of medicine.— Chicago 
department of organic chemistry, and we know of no Med. Examiner, Aug. 1869. 

QDLING ( WILLIAM), 

^-^ Lecturer on Chemistry at St. Bartholomew's Hospital, <fce. 

A COURSE OF PRACTICAL CHEMISTRY, arranged for the Use 

of Medical Students. With Illustrations. From the Fourth and Revised London Edition. 
In one neat royal 12mo. volume, cloth, $2. 



flALLOWAT (ROBERT), F.C.S., 

*~* Prof, of Applied Chemistry in the Royal College of Science for Ireland, &c. 

A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- 
don Edition. In one neat royal 12mo. volume, with illustrations,- cloth, $2 50. (Jus* 
Isstted. ) 
The success which has carried this work through repeated editions in England, and its adoption 
as a text-book in several of the leading institutions in this country, show that the author has sue- 
ceeded in the endeavor to produce a sound practical manual and book of reference for the che- 
mical student. 



Prof. Galloway's books are deservedly in high 
esteem, and this American reprint of the fifth edition 
(186.9) of his Manual of Qualitative Analysis, will be 
acceptable to many American students to whom the 
English edition is not accessible. — Am. Jour, of Sci- 
ence and Arts, Sept. 1872. 



We regard this volume as a valuable addition to 
the chemical text-books, and as particularly calcu- 
lated to instruct the student in analytical researches 
of the inorganic compounds, the important vegetable 
acids, and of compounds and various secretions and 
excretions of animal origin. — Am. Journ. of Pharm., 
Sept. 1872. 



Henry C. Lea's Publications — {Chemistry). 



11 



~DLOXAM (C.L.), 

-*~* Professor of Chemistry in King's College, London. 

CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 

don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illustra- 
tions. Cloth, $4 00 ; leather, $5 00. {Lately Issued.) 
It has been the author's endeavor to produce a Treatise on Chemistry sufficiently comprehen- 
sive for those studying the science as a branch of %. neral education, and one which a student 
may use with advantage in pursuing his chemical stud s at one of the colleges or medical schools. 
The special attention devoted to Metallurgy and some other branches of Applied Chemistry renders 
the work especially useful to those who are being educated for employment in manufacture. 



We have iu this -work a complete and most excel- 
lent text-book for the use of schools, and can heart- 
ily recommend it as such. — Boston Med. and Surg. 
Journ., May 28, 1874. 

Of »11 the numerous -works upon elementary chem- 
istry that have been published within the last few 
years, we can point to none that, in fulness, accuracy, 
and simplicity, can surpass this; while, in the num- 
ber and detailed descriptions of experiments, as also 
in the profuseness of its illustrations, we believe it 
stands above any similar work published in this coun- 
try The statements made are clear and con- 
cise, and every step proved by an abundance of ex- 
periments, which excite our admiration as much by 
their simplicity as by their direct conclusiveness. — 
Chicago Med. Examiner, Nov. 15, IS73. 

It is seldom that in the same compass so complete 
and interesting a compendium of the leading facts of 
chemistry is offered. — Druggists' Circular, Nov. '73. 
The above is the title of a work which we can most 
conscientiously recommend to students of chemistry. 
It is as easy as a work on chemistry could be made, 
at the same lime that it presents a full account of that 
science as it now stauds. We have spoken of the 
workas admirably adapted to the wants of students ; 
it is quite as well suited to the requirements of prac- 
titioners who wish to review their chemistry, or have 
occasion to refresh their memories on any point re- 
lating to it. In a word, it is a book to be read by all 
who wish to know what is the chemistry of the pre- 
sent day.— American Practitioner, Nov. 1873. 

Among the various works upon general chemistry 
issued, we know of none that will supply the average 
wants of the student or teacher better than this. — 
Indiana Jo urn. of Med., Nov. 1873. 

We cordially welcome this American reprint of a 
work which has already won for itself so substantial 
a reputation in England . Professor Bloxam has con- 
densed into a wonderfully small com -ass all the im- 
portant principles and facts of chemical science. 
Thoroughly imbued with an enthusiastic love for the 
science he expounds, he has stripped it of all need- 
less technicalities, and rounded out its hard outlines 
by a fulness of illustration that cannot fail to attract 
and delight the student. The details of illustrative 



experiment have been worked up with especial care, 
and many of the experiments described are both new 
and striking. — Detroit Rev. of Med. and Pharm., 
Nov. 1S73. 

One of the best text-books of chemistry yet pub- 
lished. — Chicago Med. Journ., Nov. 187a. 

This is an excellent work, well adapted for the be- 
ginner and the advanced student of chemistry. — Am. 
Journ. of Pharm., Nov. 1873. 

Probably the most valuable, and at the same time 
practical, text-book on general chemistry extant in 
our language.— Kansas City Med. Journ., Dec. 1873. 

Prof. Bloxam possessespre-eminently the inestima- 
ble gift of perspicuity. It is a pleasure to read his 
books, for he is capable of making very plain what 
other authors frequently have left very obscure. — 
Va. Clinical Record, Nov. 1S73. 

It would be difficult for a practical chemist and 
teacher to find any material fault with this most ad- 
mirable treatise. The author has given us almost a 
cyclopedia within the limits of aeon venient volume, 
and has done so without penning the useless para- 
graphs too commonly making up a great part of the 
bulk of many cumbrous works. The progressive sci- 
entist is not disappointed when he looks for the record 
of new and valuable processes and discoveries, while 
the cautious conservative does not find its pages mo- 
nopolized by uncertain theories and speculations. A 
peculiar point of excellence is the crystallized form of 
expression in which great truths are expressed in 
very short paragraphs. One is surprised at the brief 
space allotted to an important topic, and yet, after 
reading it, he feels that little, if any more, should 
have been said. Altogether, it is seldom you see a 
text-book so nearly faultless.— Cincinnati Lancet 
Nov. 1873. 

Prjfessor Bloxam has given us a most excellent 
and useful practical treitise. His 666 pages are 
crowded with facts and experiments, nearly all well 
chosen, and many quite new, even to scientific men. 
. . . It is astonishing how much info rmation he often 
conveys in a few paragraphs. We might quote fifty 
instances of this. — Chemical News. 



TUOHLER AND FITTIG. 

rr OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- 

ditions from the Eighth German Edition. By Ira Remsen, M.D., Ph.D., Professor of 
Chemistry and Physics in Williams College, Mass. In one handsome volume, royal 12mo 
of 550 pp., cloth, $3. 
As the numerous editions of the original attest, this work is the leading text-book and standard 
authority throughout Germany on its important and intricate subject — a position won for it by 
the clearness and conciseness which are its distinguishing characteristics. The translation has 
been executed with the approbation of Profs. Wbhler and Fittig, and numerous additions and 
alterations have been introduced, so as to render it in every respect on a level with the most 
advanced condition of the science. 

J^O WMAN {JOHN E.) , M. D. 

PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited 

by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Sixth 
American, from the fourth and revised English Edition. In one neat volume, royal 12mo. , 
pp. 351, with numerous illustrations, cloth, $2 25. 
JjY THE SAME AUTHOR. (Lately Issued.) 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 

ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- 
ous illustrations. In one neat vol., royal 12mo., cloth, $2 25. 



K2f APP'S TECHNOLOGY ; or Chemistry Applied to 
the Arts, and to Manufactures. With American 
additions, by Prof. Waltbs R. Jghsson. In two 



very handsome octavo volumes, with 600 wood 
engravings, oloth, $6 00 . 



12 Henry 0. Lea's Publications — (Mat Med. and Therapeutics). 



pARRlSH {EDWARD), 

Late. Professor of Materia Medica in the Philadelphia College of Pharmacy. 

A TREATISE ON PHARMACY. Designed as a Text-Book for the 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In on© 
handsome octavo volume of 977 pages, with 280 illustrations; cloth, $5 50; leather, $6 50. 
I Just Issued.) 
The delay in the appearance of the new U. S. Pharmacopoeia, and the sudden death of the au 
thor, have postponed the preparation of this new edition beyond the period expected. The note 
and memoranda left by Mr. Parrish have been placed in the hands of the editor, Mr. Wiegand, 
who has labored assiduously to embody in the work all the improvements of pharmaceutical sci- 
ence which have been introduced during he last ten years. It is therefore hoped that the new 
edition will fully maintain the reputation which the volume has heretofore enjoyed as a standard 
text-book and work of reference for all engaged in the preparation and dispensing of medicines. 
Of Dr Parrish's great work on pharmacy it only I an honored place on our own bookshelves. — Dublin 
remains to he said thai the editor has accomplished j Med. Press and Circular, Aug. 12, 1874. 
his work so well as to maintain, in this fourth edi- ! We expressed our opinion of a former edition in 

terms of unqualified praise, and we are in no mood 
to detract from that opinion in reference to the pre- 
sent edition, the preparation of which has fallen into 
competent hands. It is a hook with which no pharma- 
cist can dispense, and from which no physician can 
fail to derive much information of value to him in 
practice. — Pacific Med and Surg. Journ., June, '74. 

With these few remarks we heartily commend the 
work, and have no doubt that it will maintain its 
old reputation as a text-book for the student, and a 
work of reference for the more experienced physi- 
cian and pharmacist . — Chicago Med. Examiner, 
June 15, 1874. 

Perhaps one, if not the most important book upon 
pharmacy which has appeared in the English lam 
guage has emanated from the transatlantic press. 
"Parrish's Pharmacy" is a well-known work on this 
side of the water, and the fact shows us that a really 
useful work never becomes merely local in its fame. 
Thanks to the judicious editing of Mr. Wiegand, the 
posthumous edition of "Parrish" has been saved to 
the public with all the mature experience of its au- 
thor, ami perhaps none the worse for a dash of new 
blood. — Land. Pharm. Journal, Oct. 17, 1874. 



in this fourth 
tion, the high standard of excellence which it bad 
attained in previous editions, under the editorship of 
its accomplished author. This has not been accom 
plished without much labor, and many additions and 
improvements, involving changes in the arrangement 
of the several parts of the work, and the addition of 
much new matter. Willi the modifications thus ef- 
fected it constitutes, as now presented, a compendium 
of the science and art indispensable to the pharma- 
cist, and of the utmost value to every practitioner 
of medicine desirous of familiarizing himself with 
the pharmaceutical preparation of the articles which 
he prescribes for his patients. — Chicago Med. Journ., 
July, 1874. 

The work is eminently practical, and has the rare 
merit of beiug readable and interesting, while it pre- 
serves a strictly scientific character. The whole work 
reflects the greatest credit on author, editor, and pub- 
lisher It will convey some idea of theliberality which 
has been bestowed upon its production when we men- 
tion that there are no less than 2S0 carefully executed 
illustrations. In conclusion, we heartily recommend 
the work, not only to pharmacists, but also to the 
multitude of medical practitioners who are obliged 
to compound their own medicines. It will ever hold 






VTILLE {ALFRED), M.D., 

*3 Professor of Theory and Practice of Medicine in the University of Penna. 

THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and History, 

Fourth edit., revised and enlarged. In two large and handsome 8vo. vols, of about 2000 

pages. Cloth, $10; leather, $12. {Now Ready.) 

The care bestowed by the author on the revision of this edition has kept the work out of th e 

market for nearly two years, and has increased its size about two hundred and fifty pages. Not" 

withstanding this enlargement, the price has been kept at the former very moderate rate. A few 

notices of former editions are subjoined. 



Dr. Stille's splendid work on therapeutics and ma- 
teria medica. — London Med. Times, April 8, 1865. 

Dr. Stille stands to-day one of the best and most 
honored representatives at home and abroad, of Ame- 
rican medicine ; and these volumes, a library in them- 
selves, a treasure-house for every studious physician, 
assure his fame even had he done nothing more. — The 
Western Journal of Medicine, Dec. 1868. 

We regard this work as the best one on Materia 
Medica in the English language, and as such it de- 
serves the favor it has received. — Am. Journ. Medi- 
cal Sciences, July 1868. 

We need not dwell on the merits of the third edition 
of this magnificently conceived work. It is the work 
on Materia Medica, in which Therapeutics are prima- 
rily considered — the mere natural history of drugs 
being briefly disposed of. To medical practitioners 
this is a very valuable conception. It is wonderful 
how much of the riches of the literature of Materia 
Medica has been condensed into this book. The refer- 
ences alone would make it worth possessing. But it 
Is not a mere compilation. The writer exercises a 
good judgment of his own on the great doctrines and 
points of Therapeutics. For purposes of practice, 
Still6's book is almost unique as a repertory of in- 
formation, empirical and scientific, on the actions and 
uses of medicines. — London Lancet, Oct. 31, 1868. 

Through the former editions, the professional world 
Is well acquainted with this work. At home and j 



abroad its reputation as a standard treatise on Materia 
Medica is securely established. It is second to no 
work on the subject in the English tongue, and, in- 
deed, is decidedly superior, in some respects, to any 
other. — Pacific Med. and Surg Journal, July, 1863. 

Still6's Therapeutics is incomparably the best worls 
on the subject.— N. Y. Med. Gazette, Sept. 26, 1868. 

Dr. Still6's work is becoming the best known of any 
of our treatises on Materia Medica. . . . One of th« 
most valuable works in the language on the subjects 
of which it treats.— -N. Y. Med. Journal, Oct. 1868. 

The rapid exhaustion of two editions of Prof. Still6'» 
scholarly work, and the consequent necessity for a 
third edition, is sufficient evidence of the high esti- 
mate placed upon it by the profession. It is no exag- 
geration to say that there is no superior work upon 
the subject in the English language. The present 
edition is fully up to the most recent advance in th<a 
science and art of therapeutics. — Leavenworth Medi- 
cal Herald, Aug. 1868. 

The work of Prof. Stille' has rapidly taken a high 
place in professional esteem, and to say that a third 
edition is demanded and now appears before as, suffi- 
ciently attests the firm-position this treatise has made 
for itself. As a work of great research, and scholar- 
ship, it is safe to say we have nothing superior. It in 
exceedingly full, and the busy practitioner will find 
ample suggestions upon almost every important point 
of therapeutics.— Cincinnati Lancet, Aug. 1868. 






Henry C. Lea's Publications — {Mat. Med. and Therapeutics). 13 



/7RIFFITH {ROBERT E.), M.D. 

A UNIVERSAL FORMULARY, Containing the Methods of Prepar- 
ing and Administering Officinal and other Medicines. The whole adapted to Physician; and 
Pharmaceutists. Third edition, thoroughly revised, with numerous additions, bj John M. 
Maisch, Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large 
andhandsome octavo volume of about 800 pages, cloth, $4 50 ; leather, $5 50. (Just Issued.) 
This work has long been known for the vast amount of information which it presents in a con- 
densed form, arranged for easy reference. The new edition has received the most careful revi- 
sion at the competent hands of Professor Maisch, who has brought the whole up to the standard of 
the most recent authorities. More than eighty new headings of remedies have been introduced, 
the entire work has been thoroughly remodelled, and whatever has seemed to be obsolete has been 
omitted. As a comparative view of the United States, the British, the German, and the French 
Pharmacopoeias, together with an immense amount of unofficinal formulas, it affords to the prac- 
titioner and pharmaceutist an aid in their daily avocations not to be found elsewhere, while three 
indexes, one of "Diseases and their Remedies," one of Pharmaceutical Names, and a General 
Index, afford an easy key to the alphabetical arrangement adopted in the text. 

To the druggist a good formulary is simply indis- 



The young practitioner will find the work invalu- 
able in suggesting eligible modes of administering 
many remedies. — Am. Journ. of Pharm., Feb. 1874. 

Our copy of Griffith's Formulary, after long use, 
first in the dispensing shop, and afterwards in our 
medical practice, had gradually fallen behind in the 
onward march of materia medica, pharmacy, and 
therapeutics, until we had ceased to cousult'it as a 



pensable, and perhaps no formulary has been rnon 
extensively used than the well-known work before 
us. Many physicians have to officiate, also, as drug- 
gists. This is true especially of the country physi- 
cian, and a woi - k which shall teach him the means 
by which to administer or combine his remedies in 
the most efficacious and pleasant manner, will al- 
ways hold its place upon his shelf. A formulary of 



j -i v i 'r ; ~".~^v,nov.^ „« v«"oun ii,™- a, W avs hold its place upon nis shell. A torrant 

daily book of reference So completely has Prof. | this kind is of beiieflt als0 to the city physic 



Maisch reformed, remodelled, and rejuvenated it 
the new edition, we shall gladly welcome it back to 
our table again beside Dunglison, Webster, and Wood 
& Bache. The publisher could not have been more 
fortunate in the selection of an editor. Prof. Maisch 
is eminently the man for the work, and he has done 
it thoroughly and ably. To enumerate the altera- 
tions, amendments, and additions would be an end- 
less task ; everywhere we are greeted with the evi- 
dences of his labor. Following the Formulary, is an 
addendum of useful Recipes, Dietetic Preparations, 
List of Incompatible*, Posological table, table of 
Pharmaceutical Names, Officinal Preparations and 
Directions, Poisons. Antidotes and Treatment, and 
copious indices, which afford ready access to all parts 
of the work. We unhesitatingly commend the book 
as being the best, of its kiud, within our knowledge. 
—Atlanta Med. and Surg. Journ., Feb. 1874. 



largest practice.— Cincinnati Clinic, Feb. 21, 1S74. 

The Formulary has already proved itself accepta- 
ble to the medical profession, and we do not hesitate 
to say that the third edition is much improved, and 
of greater practical value, in consequence of the care- 
ful revision of Prof Maisch. — Chicago Med. Exam- 
iner, March 15, 1874. 

A more complete formulary thau it is in its pres- 
ent form the pharmacist or physician could hardly 
desire. To the first some such work is indispensa- 
ble, and it is hardly less essential to the practitiouer 
who compounds his own medicines. Much of what 
is coutained iu the introduction ought to b3 com- 
mitted to memory by every student of medi-nae. 
As a help to physicians it will be found invaluable, 
and doubtless will make its way into libraries not 
already supplied with a standard work of the kind. 
— The American Practitioner, Louisville, July, '74. 



'fJLLIS {BENJAMIN), M.D. 

THE MEDICAL FORMULARY: being a Collection of Prescriptions 

derived from the writings and practice of many of the most eminent physicians of America 
and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The 
whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- 
tion, carefully revised and much improved by Albert H. Smith, M. D. In one volume 8 ve. 
of 376 pages, cloth, $3 00. 



pEREIRA {JONATHAN), M.D., F.R.S. and L.S. 
X MATERIA MEDICA AND THERAPEUTICS; being an Abridg. 

ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with 
the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and 
Druggists, Medical and Pharmaceutical Students, &c. By P. J. Farre, M.D. , Senior 
Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia ; 
assisted by Robert Bentley, M.R.C.S., Professor of Materia Medica and Botany to the 
Pharmaceutical Society of Great Britain; and by Robert Warington, F.R.S. , Chemical 
Operator to the Society of Apothecaries. With numerous additions and references to the 
United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the 
University of Pennsylvania. In one large and handsome octavo volume of 1040 closely 
printed pages, with 236 illustrations, cloth, $7 00; leather, raised bands, $8 00. 



DTJNGLISON'S NEW REMEDIES. WITH FORMULA 
FOR THEIR PREPARATION AND ADMINISTRA- 
TION. Seventh edition, with extensive additions. 
One vol. 8vo., pp. 770; cloth. $4 00. 

BOYLE'S MATERIA MEDICA AND THERAPEU- 
TICS. Edited by Joseph Carson, M. D. With 
ninety-eight illustrations. 1 vol. 8vo., pp. 700, 
cloth. $3 00. 

CARSON'S SYNOPSIS OF THE LECTURES ON MA- 
TERIA MEDICA AND PHARMACY, delivered in 
the University of Pennsylvania. Fourth and re- 
vised edition. Cloth, $3. 



:HRISTISON'S DISPENSATORY. With copious ad 
^itirms. snd 213 large wood-engravings Bv R. 
Eglesfeld Griffith, M.D. One vol. 8vo., pp. 1000; 
cloth. $4 00. 

CARPENTER'S PRIZE ESSAY ON THE USE OF 
Alcoholic Liquors in Health and Disease. New 
edition, with a Preface by D. F. Condte, M.D., and 
explanations of scientific words. In one neat 12mo. 
volume, pp. 178, cloth. 60 cents. 

De JONGH ON THE THREE KINDS OF COD-LIYER 
Oil, with their Chemical and Therapeutic Pro- 
perties. 1 vol. 12mo., cloth. 75 cents. 



14 



Henry C. Lea's Publications — (Pathology, &c). 



JjlENWICK {SAMUEL), M.D., 

-*- Assistant Physician to the London Hospital. 

THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 

Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. 
In one very handsome volume, royal 12mo., cloth, $2 25. {Just Issued.) 
The very great success which this work has obtained in England, shows that it has supplied an 
admitted want among elementary books for the guidance of students and junior practitioners. 
Taking up in order each portion of the body or class of disease, the author has endeavored to 
present in simple language the value of symptoms, so as to lead the student to a correct appreci- 
ation of the pathological changes indicated by them. The latest investigations have been care- 
fully introduced into the present edition, so that it may fairly be considered as on a level with 
the most advanced condition of medical science. 



Of the many guide-books on medical diaguos-as, 
claimed to be written for the special instruction of 
students, this is the best. The author is evidently a 
well-read and accomplished physician, and he knows 
how to 'each practical medicine. The charm of sim- 
plicity is not the leastintprestingfeaturein theman- 
nerin which Dr. Fenwick conveys instruction. There 
are few books of this size on practical medicine that 
contain so much and convey it so well as the volume 
before us. It, is a book we can sincerely recommend 
to the student for direct instruction, and to the prac- 
titioner as a ready and useful aid to his memory. — 
Am. Jo urn. of Syphiloyraphy, Jan. 1874. 

It covers the ground of medical diagnosis in a con- 



cise, practical manner, well calculated to assist the 
student in forming a correct, thorough, and system- 
atic method of examination and diagnosis of disease. 
The illustrations are numerous, and finely executed. 
Those illustrative of the microscopic appearance of 
morbid tissue, &c, are especially clear and distinct. 
— Chicago Med. Examiner, Nov. 1£73. 

So far superior to any offered to students that the 
colleges of this country should recommend it to their 
respective classes. — N. 0. Med. and Surg. Journ., 
March, 1874. 

This little book ought to be in the possession of 
every medical student. — Boston Medical and Surg. 
Journ., Jan. 15, 1874. 



o 



RE EN (T. HENRY), M.D., 

Lecturer on Pathology and Morbid Anatomy at Charing-Oross Hospital Medical School. 

PATHOLOGY AND MORBID ANATOMY. With numerous Illus- 

trations on Wood. In one very handsome octavo volume of over 250 pages, cloth, $2 50. 

{Lately Ptiblished.) 

thology and morbid anatomy. The author shows that 
he has been not only a student of the teachings of his 
confreres in this branch of science, but a practical 
and conscientious laborer in the post-mortem cham- 
ber. The work will provea useful one to the great 
mass of students and practitioners whose time for de- 
votion to this class of studies is limited.— Am. Journ. 
of Syphilography, April, 1872. 



We have been very much pleased by our perusal of 
this little volume. It is the only one of the kind with 
which we are acquainted, and practitioners as well 
as students will find it a very useful guide; for the 
information is up to the day, well and compactly ar- 
ranged, without being at all scanty. — London Lan- 
cet, Oct. 7, 1871. 

It embodies in a comparatively small space a clear 
statement of the present state of our knowledge of pa- 



GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. 
Translated, with Notes and Additions, by Joseph 
Leidy, M. D. In one volume, very large imperial 
quarto, with 320 copper-plate figures, plain and 
colored, cloth. $4 00. 

JONES AND SIEVEKING'S PATHOLOGICAL ANA- 
TOMY. With 397 wood-cuts. 1 vol. 8vo., of nearly 
750 pages, cloth. $3 50. . 

HOLLAND'S MEDICAL NOTES AND .REFLEC- 
TIONS. 1 vol. 8vo., pp. 500, cloth. $3 50. 

WHAT TO OBSERVE AT THE BEDSIDE AND AFTEI 
Death in Medical Cases. Published under th€ 
authority of the London Society for Medical Obser- 
vation. From the second London edition. 1 vol. 
royal 12mo., cloth. $1 00. 



LA EOCHE ON YELLOW FEVEE, considered in its 
Historical, Pathological, Etiological, and Therapeu- 
tical Relations. In two large and handsome octavo 
volumes of nearly 1500 pages, cloth. $7 00. 

LAYCOCK'S LECTURES ON THE PRINCIPLES 
and Methods of Medical Observation and Re- 
search. For the use of advanced students and 
junior practitioners. In one very neat royal 12mo. 
volume, cloth. $1 00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With Additions by D. F. Condib, 
M D. 1 vol. 8vo., pp. 600, cloth. $2 50. 

TODD'S CLINICAL LECTURES ON CERTAIN ACUTE 
Diseases. In one neat octavo volume, of 320 pagee, 
cloth. $2 50. 



OTURGES (OCTAVIUS), M.D. Cantab., 

^ Fellow of the Royal College of Physicians, &c. d-c, 

AN INTRODUCTION TO THE STUDY OF CLINICAL MED- 
ICINE. Being a Guide to the Investigation of Disease, for the Use of Students. In one 
handsome 12mo. volume, cloth, $1 25. {Just Issued.) 



D 



AVIS (NATHAN S.), 

Prof, of Principles and Practice of Medicine, etc., in Chicago Med. College. 

CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES; 

being a collection of the Clinical Lectures delivered in the Medical Wards of Mercy Hos- 
pital, Chicago. Edited by Frank H. Davis, M.D. Second edition, enlarged. In one 
handsome royal 12mo. volume. Cloth, $1 75. {Now Ready.) 



OTOKES (WILLIAM), M.D., D.G.L., F.R.S., 

*-3 Begins Professor of Physic in the Univ. of Dublin, &c. 

LECTURES ON FEVER, delivered in the Theatre of the Meath Hos- 

pital and County of Dublin Infirmary. Edited by John Willtam Moore, M.D , Assistant 
Physician to the Cork Street Fever llospital. In one neat octavo volume. (Preparing.) 
^* # To appear in the " Medical News and Library" for 1875. 



Henry C. Lea's Publications — {Practice of Medicine). 



15 



IjTLINT (AUSTIN), M.D., 

-*• Professor of the Principles and Practice of Medicine in Bellevue Med. College, 2T. Y 

A TREATISE OX THE PRINCIPLES AXD PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth 

edition, revised and enlarged. In one large and closely printed octavo volume of about 1 100 

pages ; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. {Just Issued.) 

By common consent of the English and American medical press, this work has been assigned 

to the highest position as a complete and compendious text-book on the most advanced condition 

of medical science. At the very moderate price at which it is offered it will be found one of the 

Oheapest volumes now before the profession. A few notices of previous editions are subjoined. 



Admirable and unequalled 
Medicine, Nov. 1S69. 



■Western Journal of 



Dr. Flint's work, though claiming no higher title 
than that of a text-book, is really more. He is a man 
of large clinical experience, and his book is full of 
such masterly descriptions of disease as can only be 
drawn by a man intimately acquainted with their 
various forms. It is not so long since we had the 
pleasure of reviewing his first edition, and we recog- 
nize a great improvement, especially in the general 
part of the work. It is a work which we can cordially 
recommend to our readers as fully abreast of the sci- 
ence of the day.— Edinburgh Med. Journal, Oct. '69. 

One of the best works of the kind for the practi- 
tioner, and the most convenient of all for the student. 
— Am. Journ. Med. Sciences, Jan. 1869. 

This work, which stands pre-eminently as the ad- 
vance standard of medical science up to the present 
time in the practice of medicine, has for its author 
one who is well and widely known as one of the 
leading practitioners of this continent. In fact, it is 
seldom that any work is ever issued from the press 
more deserving of universal recommendation. — Do- 
minion Med. Journal, May, 1869. 

The third edition of this most excellent book scarce- 
ly needs any commendation from us. The volume, 
as it stands now, is really a marvel : first of all, it is 

JDY THE SAME AUTHOR. 

ESSAYS OX COXSERYATIYE MEDICINE AXD KINDRED 

TOPICS. In one very handsome royal 12mo. volume. Cloth, $1 38. (Jztst Issued.) 

CONTENTS, 

I. Conservative Medicine. II. Conservative Medicine as applied to Therapeutics. III. Con- 
servative Medicine as applied to Hygiene. IV. Medicine in the Past, the Present, and the Fu- 
ture. V. Alimentation in D sease. VI. Tolerance of Disease. VII. On the Age cy of the 
Mind in Etiology, Prophylaxis, and Therapeutics. VIII. Divine design as exemplified in the 
Natural History of Disease. 

~UTA TSON (THOMAS), M. D., §-c. 

LECTURES OX THE PRIX T CIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
ations, by Henry Hartshorxe, M.D., Professor of Hygiene in the University of Pennsylv- 
nia. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. {Lately Published.) 



xcellently printed and bound — and we encounter 
that luxury of America, the ready-cut pages, which 
the Yankees are 'cute enough to insist upon — nor are 
these by any means trifles ; but the contents of the 
book are astonishing. Not only is it wonderful that 
iny one man can have grasped in his mind the whole 
scope of medicine with that vigor which Dr. Flint 
shows, hut the condensed yet clear way in which 
this is done is a perfect literary triumph. Dr. Flint 
Is pre-eminently one of the strong men, whose right 
to do this kind of thing is well admitted ; and we say 
20 more than the truth when we afiBrm that he is 
7ery nearly the only living man that could do it with 
men results as the volume before us. — The London 
Practitioner, March, 1869. 

This is in some respects the best text-book of medi- 
line in our language, and it is highly appreciated on 
:he other side of the Atlantic, inasmuch as the first 
edition was exhausted in a few months. The second 
edition was little more than a reprint, but the present 
has, as the author says, been thoroughly revised. 
Much valuable matter has been added, and by mak- 
ing the type smaller, the bulk of the volume* is not 
much increased. The weak point in many American 
works is pathology, but Dr. Flint has taken peculiar 
pains on this point, greatly to the value of the book. 
— London Med. Times and Gazette, Feb. 6, 1869. 



It is a subject for congratulation and for thankful- 
ness that Sir Thomas Watson, during a period of com- 
parative leisure, after a long, laborious, and most 
honorable professional career, while retaining full 
possession of his high mental faculties, should have 
employed the opportunity to submit his Lectures to 
a more thorough revision than was possible during 
the earlier and busier period of his life. Carefully 
passing in review some of the most intricate and im- 
portant pathological and practical questions, there- 
suits of his clear insight and his calm judgment are 
now recorded for the benefit of mankind, in language 
which, for precision, vigor, and classical elegance, has 
rarely been equalled, and never surpassed The re- 
vision has evidently been most carefully done, and 
the results appear in almost every page. — Brit. Med. 
Journ., Oct. 14, 1871. 

The lectures are so well known and so justly 
appreciated, that it is scarcely necessary to do 
more than call attention to the special advantages 
of the last over previous editions. The author's 



rare comhinatior of great scientific attainments com- 
bined with wonderful forensic eloquence has exerted 
extraordinary influence over the last two generations 
of physicians. His clinical descriptions of most dis- 
eases have never been equalled; and on this score 
at least his work will live long in the future. The 
work will be sought by all who appreciate a great 
book. — Amer. Journ. of Syphilography. July, 1S72. 
We are exceedingly gratified at the reception of 
this new edition of Watson, pre-eminently the prince 
of English authors, on "Practice." We, who read 
the first edition shall never forget the great pleasure 
and profit we derived from its graphic delineations 
of disease, its vigorous style and splendid English. 
Maturity of years, extensive observation, profound 
research, and yet continuous enthusiasm, have com- 
bined to give us in this latest edition a model of pro- 
fessional excellence in teaching with rare beauty in 
the mode of communication. But this classic needs 
no eulogium of ours. — Chicago Med. Journ., July, 
1872. 



D 



UNGLISON, FORBES, TWEED IE, AND CONOLLY. 

THE CYCLOPAEDIA OF PRACTICAL MEDICINE : comprising 

Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, 
Diseases of Women and Children, Medical Jurisprudence, <fcc. &c. In four large super-royal 
octavo volumes, of 3254 double-columned pages, strongly and handsomely bound in leather, 
$15; cloth, $11. 



16 Henry C. Lea's Publications — (Practice of Medicine). 

TTARTSHORNE {HENRY), 31. D., 

•*•-*- Professor of Hygiene in the University of Pennsylvania. 

ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEM- 

CINE. A handy-book for Students and Practitioners. Fourth edition, revised and im- 
proved. With about one hundred illustrations. In one handsome royal 12mo. volume, 
of about 550 pages, cloth, $2 63 ; half bound, $2 88. (Just Ready.) 
The thorough manner in which the author has labored to fully represent in this favorite hand- 
book the most advanced condition of practical medicine is shown by the fact that the present 
edition contains more than 250 additions, representing the investigations of 172 authors not re- 
ferred to in previous editions. Notwithstanding an enlargement of the page, the size has been 
increased by sixty pages. A number of illustrations have been introduced which it is hoped 
will facilitate the comprehension of details by the reader, and no effort has been spared to make 
the volume worthy a continuance of the very great favor with which it has hitherto been received. 

The work is brought fully up with all the recent 
advances in medicine, is admirably condensed, and 
yet sufficiently explicit lor all the purposes intended, 
thus making it by far the best work of its character 



a- published.— Cincinnati Clinic, Oct. 24, 1874. 

We have already had occasion to notice the previ- 
ous editions of this work. It is excellent of its kind. 
The author has given a very careful revision, in view 
of the rapid progress of medical science. — N. Y. Med. 
Journ., Nov. 1S74. 



Without doubt the best book of the kind published 
in the English language. — St. Louis Med. and Surg. 
Jo2irn., Nov. 1874. 

As a handbook, which clearly sets forth the essen- 
tials of the principles and practice of medicine, we 
do not know of its equal. — Va. Med. Monthly. 

As a brief, condensed, but comprehensive hand- 
book, it cannot be improved upon. — Chicago Med. 
Examiner, Nov. 35, 1874. 



PAVY{F. W.),M.D.,FR.S., 
Senior Asst. Physician to and Lecturer on Physiology, at Guy's Hospital, &c. 

A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- 

ders and their Treatment. From the second London edition. In one handsome volume, 
small octavo, cloth, $2 00. 
J> T THE SAME A UTHOR. (Just Ready. 

A TREATISE ON FOOD AND DIETETICS, PHYSIOLOGI- 
CALLY AND THERAPEUTICALLY" CONSIDERED. In one handsome octavo volume 
of nearly 600 pages, cloth, $4 75. 

SUMMARY OF CONTENTS. 

Introductory Remarks on the Dynamic Relations of Food — On the Origination of Food — The 
Constituent Relations of Food — Alimentary Principles, their Classification, Chemical Relations, 
Digestion, Assimilation, and Physiological Uses — Nitrogenous Alimentary Principles — Non-Ni- 
trogenous Alimentary Principles — The Carbo-Hydrates — The Inorganic Alimentary Principles- 
Alimentary Substances — Animal Alimentary Substances — Vegetable Alimentary Substances — 
Beverages — Condiments — The Preservation of Food — Principles of Dietetics — Practical Dietetics 
— Diet of Infants — Diet for Training — Therapeutic Dietetics — Dietetic Preparations for the Inva- 
lid — Hospital Dietaries. 

(1HAMDERS (T. K.), M.D. {Now Ready.) 

v/ Consulting Physician to St. Mary's Hospital, London, &c. 

A MANUAL OF DIET AND REGIMEN IN HEALTH AND SICK- 

NESS. In one handsome octavo volume. Cloth, $2 75. 
The aims of this handbook are purely practical, and therefore it has not been thought right 
to increase its size by the addition of the chemical, botanical, and industrial learning which 
rapidly collects round the nucleus of every article interesting as an eatable. Space has been 
thus gained for a full discussion of many matters connecting food and drink with the daily cur- 
rent of social life, which the position of the author as a practising physician has led him to 
believe highly important to the present and future of our race. — Preface. 

SUMMAKY OF CONTENTS. 

Part I. General Dietetics. Chap. I. Theories of Dietetics. II. On the Choice of Food. III. 
On the Preparation of Food. IV. On Digestion and Nutrition. 

Part II. Special Dietetics of Health. Chap. I. Regimen of Infancy and Motherhood. II. 
Regimen of Childhood and Youth. III. Commercial Life. IV. Literary and Professional Life. 
V. Noxious Trades. VI. Athletic Training. VII. Hints for Healthy Travellers. VIII. Effects 
of Climate. IX. Starvation, Poverty, and Fasting. X. The Decline of Life. XI. Alcohol. 

Part III. Dietetics in Sickness. Chap. I. Dietetics and Regimen in Acute Fevers. II. The 
Diet and Regimen of certain other Inflammatory States. III. The Diet and Regimen of Weak 
Digestion. IV. Gout and Rheumatism. V. Gravel, Stone, Albuminuria, and Diabetes. VI. 
Deficient Evacuation. VII. Nerve Disorders. VIII. Scrofula, Rickets, and Consumption. IX. 
Diseases of Heart and Arteries. 

T>Y THE SAME AUTHOR. (Lately Published.) 

RESTORATIVE MEDICINE. An Harveian Annual Oration. With 

Two Sequels. In one very handsome volume, small 12mo., cloth, $1 00. 



jnRINTON {WILLIAM), M.D., F.R.S. 
"^LECTURES ON THE DISEASES OF THE STOMACH; with an 

Introduction on its Anatomy and Physiology. From the second and enlarged London edi- 
tion. With illustrations on wood In one handsome octavo volume of about 300 pages 
cloth, $3 25. 



Henry C. Lea's Publications. 



It 



FLINT {AUSTIN), M.D., 

•*■ Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 
edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 



Dr. Flint chose a difficult subject for his researches, 
and has shown remarkable powers of observation 
and reflection, as well as great industry, in his treat- 
ment of it. His book must be considered the fullest 
and clearest practical treatise on those subjects, and 
should be in the hands of all practitioners and stu- 
dents. It is a credit to American medical literature. 
— Artier. Journ. of the Med. Sciences, July, 1S60. 

We question the fact of any recent American author 
In our profession being more extensively known, or 
more deservedly esteemed in this country than Dr. 
Flint. We willingly acknowledge his success, more 
particularly in the volume on diseases of the heart, 
jn making an extended personal clinical study avail- 



able for purposes of illustration, in connection with 
cases which have been reported by other trustworthy 
observers. — Brit, and For. Med.-Chirurg. Review. 

In regard to the merits of the work, we have no 
hesitation in pronouncing it full, accurate, and judi- 
cious. Considering the present state of science, such 
a work was much needed. It should be in the hands 
of every practitioner. — Chicago Med. Journ. 

With more than pleasure do we hail the advent of 
this work, for it fills a wide gap on the list of text- 
books for our schools, and is, for the practitioner, the 
most valuable practical work of its kind. — N. 0. Med. 
News. 



>F THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA, 

TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
of 595 pages, cloth, $4 50. 

which pervades his whole work lend an additional 
force to its thoroughly practical character, which 
cannot fail to obtain for it a place as a standard work 
on diseases of the respiratory system. 



Dr. Flint's treatise is one of the most trustworthy 
guides which we can consult. The style is clear and 
distinct, and is also concise, being free from that tend- 
ency to over-refinement and unnecessary minuteness 
which characterizes many works on the same sub- 
ject.— Dublin Medical Press, Feb. 6, 1867. 

The chapter on Phthisis is replete with interest ; 
and his remarks on the diagnosis, especially in the 
early stages, are remarkable for their acumen and 
great practical value. Dr. Flint's style is ciear and 
elegant, and the tone of freshness and originality 



London 



diseas 
Lancet, Jan. 19, 1867. 

This is an admirable book. Excellent in detail and 
execution, nothing better could be desired by the 
practitioner. Dr. Flint enriches his subject with 
much solid and not a little original observation. ~ 
Ranking's Abstract, Jan. 1867. 



J^Y THE SAME AUTHOR. 

A PRACTICAL TREATISE OX PHTHISIS— DIAGNOSIS, PROG- 
NOSIS, AND TREATMENT. IN A SERIES OF CLINICAL STUDIES. A new work, 
in preparation for early publication. In one handsome octavo volume. 
A brief table of contents is subjoined: — 

Chap. I. Morbid Anatomy. II. Etiology. III. Symptomatic Events and. Complications. 
IV. Fatality and Prognosis. V. Treatment. VI. Physical Signs and Diagnosis. 

fPVLLER {HENRY WILLIAM), M. D., 

■*• Physician to St. George's Hospital, London. 

OX DISEASES OF THE LUNGS AXD AIR-PASSAGES. Their 

Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised 
English edition. In one handsome octavo volume of about 500 pages, cloth, $3 50. 

jyiLLIAMS (C. J. B.), M.D., 

Senior Consulting Physician to the Hospital for Consumption, Brompton, and 

JfflLLIAMS {CHARLES T), M.D., 

Physician to the Hospital for Consumption. 

PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- 

ment. With an Analysis of One Thousand Cases to exemplify its duration. In one neat 
octavo volume of about 350 pages, cloth, $2 50. (Lately Published.) 

He can still speak from a more enormous experi- I After all, the grand teaching which Dr Williams has 
ence, and a closer study of the morbid processes in- | for the profession is to be found in his therapeutical 
volved iu tuberculosis, than most living men. He I chapters, and in the history of individual cases ex- 
owed it to himself, and to the importance of the sub- | tended, by dint of care, over ten, twenty, thirty, and 
ject, to embody his views in a separate work, and I sven forty years.— London Lancet, Oct. 21, 1S71. 
we are glad that he has accomplished this duty. | 



LA ROCHE ON PNEUMONIA. 1 vol. 8vo., cloth, 
of 500 pages . Price $3 00. 

SMITH ON CONSUMPTION ; ITS EARLY AND RE- 
MEDIABLE STAGES. 1 vol. 8vo., pp. 254. $2 25 



WALSHE ON THE DISEASES OF THE HEART AND 
GREAT VESSELS. Third American edition. In 
1 vol. 8vo., 420 pp., cloth. $3 00. 



FOX { WILSON), M.D., 

-*- Holme Prof, of Clinical Med., University Coll., London. 

THE DISEASES OF THE STOMACH: Being the Third Edition of 

the "Diagnosis and Treatment of the Varieties of Dyspepsia." Revised and Enlarged. 
With illustrations. In one handsome octavo volume, cloth, $2 00. (Now Ready.) 
Dr. Fox has put forth a volume of uncommon ex- I rank among works that treat of the stomach.— Am- 
cellence, which we feel very sure will take a high | Practitioner, March, 1S73. 



18 



Henry C. Lea's Publications — {Practice of Medicine). 



A 



ROBERTS {WILLIAM), M. D.. 

Lecturer on Medicine in the Manchester School of Medicine, &c. 

PRACTICAL TREATISE ON URINARY AND RENAL DIS- 

EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- 
ond American, from the Second Revised and Enlarged London Edition. In one large 
and handsome octavo volume of 616 pages, with a colored plate ; cloth, $4 50. (Lately 
Published.) 
The author has subjected this work to a very thorough revision, and has sought to embody in 
it the results of the latest experience and investigations. Although every effort has been made 
to keep it within the limits of its former size, it has been enlarged by a hundred pages, many 
new wood-cuts have been introduced, and also a colored plate representing the appearance of the 
different varieties of urine, while the price has been retained at the former very moderate rate. 
The plan, it will thus be seen, is very complete, diseases we have examined. It is peculiarly adapted 
ani the manner in which it has heen carried out is 
in the highest degree satisfactory. The characters 
of the different deposits are very well described, and 
the microscopic appearances they present are illus- 
trated by numerous well executed engravings. It 
only remains to us to strongly recommend to our 
readers Dr. Roberts's work, as containing an admira- 
ble risume of the present state of knowledge of uri- 
nary diseases, and as a safe and reliable guide to the 
clinical observer.— Edin. Med. Jour. 
The most complete and practical treatise upon renal 



to the wants of the majority of American practltion' 
ers from its clearness and simple announcement of the 
facts in relation to diagnosis and treatment of urinary 
disorders, aud contains in condensed form the invest"' 
gations of Bence Jones, Bird, Beale, Hassall, Prou 
and a host of other well-known writers upon thi 
ject. The characters of urine, physiological and pa- 
thological, as indicated to the naked eye as well as by 
microscopical and chemical investigations, are con- 
cisely represented hoth hy description and by well 
executed engravings. — Cincinnati Journ. of Med. 



ry 

I 



B 



ASH AM {W.E.), M.D., 

Senior Physician to the Westminster Hospital, &c. 

RENAL DISEASES : a Clinical Guide to their Diagnosis and Treatment. 

With illustrations. In one neat royal 12mo. volume of 304 pages, cloth, $2 00. 



The chapters on diagnosis and treatment are very 
good, and the student and young practitioner will 
find them full of valuable practical hints. The third 
part, on the urine, is excellent, and we cordially 
recommend its perusal. The author has arranged 
his matter in a somewhat novel, and, we think, use- 
ful form. Here everything can be easily found, and, 
what is more important, easily read, for all the dry 



details of larger books here acquire a new interest 
from the author's arraugement. This part of the 
book is full of good work.— Brit, and For. Medico- 
Ihirurgical Review, July, 1870. 

The easy descriptions and compact modes of state- 
ment, render the book pleasing and convenient. — Am. 
Journ. Med. Sciences, July, 1S70. 



TINCOLN {D. F.). M.D., 

-*-• Physician to the Department of Nervous Diseases, Boston Dispensary. 

ELECTRO THERAPEUTICS; 1 Concise Manual of Medical Electri- 

city. In one very neat royal 12mo. volume, cloth, with illustrations, $1 50. (Just Ready.) 

The work is convenient in size, its descriptions of 
methods and appliances are sufficiently complete for 
the geueral practitioner, and the chapters on Electro- 
physiology and diagnosis are well written and read- 
able. For those who wish a handy-book of directions 
for the employment of galvanism in medicine, this 
will serve as a very good and reliable guide. — New 
Remedies, Oct. 1874. 

It is a well written work, and calculated to meet 
the demands of the busy practitioner. It contains 
the latest researches in this important branch of med- 
icine. — Peninsular Journ. of Med., Oct. 187-1. 

Eminently practical in character. It will amply 
repay anv one for a careful perusal. — Leavenworth 
Med. Herald, Oct. 1874. 



This little book is, considering its size, one of the 
very best of the English treatises on its subject that 
has come to our notice, possessing, among others, the 
rare merit of dealing avowedly and actually with 
principles, mainly, rather than with practical details, 
thereby supplying a real waut, instead of helping 
merely to flood the literary market. Dr. Lincoln s 
style is usually remarkably clear, and the whole 
book is readable and interesting. — Boston Med. and 
Surg. Journ., July 23, 1S74. 

We have here in a small compass a great deal of 
valuable information upon the subject of Medical 
Electricity. — Canada Med. and Surg. Journ.. Nov. 
1874. 



JEE (HENRY), 

Prof of Surgery at the R^ya.l College of Surgeons of England, etc. 

LECTURES OX SYPHILIS AXD ON SOME FORMS OP LOCAL 

DISEASE AFFECTING PRINCIPALLY THE ORGANS OF GENERATION. In one 
handsome octavo volume. 

CONTENTS. 

Lectures I., II., III. General. — IV. Treatment of Syphilis — V. Treatment of Particular 
and Modified Syphilitic Affections — VI. Second Sage of Lues Venerea; Treatment — VII. Lo- 
cal Suppurating Venereal Sore; Syphilization ; Lymphatic Absorption ; Physiological Absorp- 
tion ; Twofold Inoculation — VIII. Urethral Discharges : different kinds ; Treatment; Conclu- 
sions of Hunter and Ricord — IX. Prostatic Discharges — X. Lymphatic Absorption continued 
Local Affections ; Warts and Excrescences. 



DIPHTHERIA; its Nature and Treat nent, with an 
account of the History of its Prevalence in vari- 
ous Countries. By D. D. Slade, M.D. Second and 
revised edition. In one neat royal 12mo. volume, 
cloth, (I 2.'>. 

LECTURES ON THE STUDY OF FEVER. By A. 
Hudson, M.D., M.R.I. A., Physician to the Meath 
Hospital. In one vol. Svo., cloth, $2 50. 



A TREATISE ON FEVER. By Robert D. Lyons, 
K C C. In one octavo volume of 362 pages, cloth, 
$2 2.3. 

CLINICAL OBSERVATIONS ON FUNCTIONAL 
NERVOUS DISORDERS BvC. Handfield Jones, 
M.D., Physician to St. Mary's Hospital, &c. Sec- 
ond American Edition. In one handsome octavo 
volume of 318 pages, cloth, $3 25. m m 



Henry C. Lea's Publications — ( Venereal Diseases, etc.). 



19 



jyUMSTEAD {FREEMAN J.), M.D., 

J-* Professor of Venereal Diseases at the Col. of Phys. and Surg., New York, &c. 

THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 

EASES. Including the results of recent investigations upon the subject. Third edition, 

revised and enlarged, with illustrations. In one large and handsome octavo volume of 

over 700 pages, cloth, $5 00 ; leather, $6 00. 

In preparing this standard work again for the press, the author has subjected it to a very 

thorough revision. Many portions have been rewritten, and much new matter added, in order to 

bring it completely on a level with the most advanced condition of syphilograpby, but by careful 

compression of the text of previous editions, the work has been increased by only sixty-four pages. 

The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a 

complete and trustworthy guide for the practitioner. 



It is the most complete book with which we are ac- 
quainted in the language. The latest views of the 
best authorities are put forward, and the information 
is well arranged — a great point for the student, and 
stilt more for the practitioner. The subjects of vis- 
ceral syphilis, syphilitic affections of the eyes, and 
the treatment of syphJis by repeated inoculations, are 
very fully discussed. — London Lancet, Jan. 7, 1871. 

Dr. Bumstead's work is already so universally 
known as the best treatise in the English language on 
venereal diseases, that it may seem almost superflu- ! 
ous to say more of it than that a new edition has been 
Issued. But the author's industry has rendered this j 
new edition virtually a new work, and so merits as ' 



much special commendation as if its predecessors had 
not been published. As a thoroughly practical book 
on a class of diseases which form a large share of 
nearly every physician's practice, the volume before 
us is bv far the best of which we have knowledge. — 
N. Y. Medical Gazette, Jan. 28, 1871. 

It is rare in the history of mediciue to find any one 
book which contains all that a practitioner needs to 
know; while the possessor of "Bumstead on Vene- 
real" has no occasion to look outside of its covers for 
anything practical connected with (he diagnosis, his- 
tory, or treatment of these affections. — N. Y. Medical 
Journal, March, 1871. 



flULLERIER {A.), and ttUMSTEAD {FREEMAN J.), 

**/ Surgeon to the Hdpital du Midi. -*-* Professor of 'Venereal Diseases in the College of 

Physicians and Surgeons, N. Y. 

AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 

Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at $3 
per part. 
Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are interested in this department of prac- 
tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. 
A specimen of the plates and text sent free by mail, on receipt of 25 cents. 
We wish for once that our province was not restrict- vrhich for its kind is more necessary for them to have. 



ed to methods of treatment, that we might say some- 
thine of the exquisite colored plates in this volume. 
— London Practitioner, May, 1S69. 

As a whole, it teaches all that can be taught by 
rueaiis of plates and pi'int. — London Lancet, March 
13, 1S6S. 

Superior to anything of the kind ever before issued 
on t bis continent. — Canada Med. Journal, March, : 69. 

The practitioner who desires to understand this 
branch of medicine thoroughly should obtain this, 
the most complete and best work ever published. — 
Dominion Med. Journal, May, 1869. 

This is a work of master hands on both sides. M. 
Cul lerier is scarcely second to, we think we may truly 
say is a peer of the illustrious and venerable Ricord, 
while in this country we do not hesitate to say that 
Br Bumstead, as an authority, is without a rival 
Assuring our readers that these illustrations tell the 
whole history of venereal disease, from its ince*ption 
to its end, we do not know a single medical work, 



— Calif irnia Med. Gazette, March, 1S69. 

The most splendidly illustrated work in the lan- 
guage, and in our opinion far more useful than the 
French original. — Am. Journ. Med. Sciences, Jan. '69. 

The fifth and concluding number of this magnificent 
work has reached us, and we have no hesitation in 
saying that its illustrations surpass those of previous 
numbers. — Boston Med. and Surg. Journal, Jan. 14, 
1869. 

Other writers besides M. Cullerier have given us a 
good account of the diseases of which he treats, but 
no one has furnished us with such a complete series 
of illustrations of the venereal diseases. There is, 
however, an additional interest and value possessed 
by the volume before us ; for it is an American reprint 
and translation of M. Cullerier's work, with inci- 
dental remarks by one of the most eminent American 
syphilographers, Mr. Bumstead. — Brit, and For. 
Medico- Chir . Review, July, 1869. 



JJILL {BERKELEY), 

Surgeon to the Lock Hospital, London. 

ON SYPHILIS AND LOCAL 

one handsome octavo volume ; cloth, $3 
Bringing, as it does, the entire literature of the dis- 
ease down to th* present day, and giving with great 
ability the results of modern research, it is in every 
respect a most desirable work, and one which should 
find a place in the library of every surgeon. — Cali- 
fornia Med. Gazette, June, 1869. 

Considering the scope of the book and the careful 
attention to the manifold aspects and details of its 
subject, it is wonderfully concise. All these qualities 
render it an especially valuable book to the beginner, 



DISORDERS. In 



CONTAGIOUS 

25. 

to whom we would most earnestly recommend its 
study ; while it is no less useful to the practitioner. — 
St. Louis Med. and Surg. Journal, May, 1869. 

The most convenient and ready book of reference 
we have met with. — N. Y. Med. Record, May 1, 1869. 

Most admirably arranged for both student and prac- 
titioner, no other work on the subject equals it ; it is 
more simple, more easily studied. — Buffalo Med. and 
Surg. Journal, March, 1869. 



J A COMPLETE TREATISE ON VENEREAL DISEASES. Trans- 

lated from the Second Enlarged German Edition, by Frederic R. Sturgis, M.D In one 
octavo volume, with illustrations. {Preparing.) 



20 



Henry C. Lea's Publications — (Diseases of the Skin). 



WILSON. {ERASMUS), F.R.S. 

ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- 

enth American, from the sixth and enlarged English edition. In one large octavo volume 
of over S00 pages, $5. 

A SERIES OF PLATES ILLUSTRATING " WILSON ON DIS- 
EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- 
teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, 
and embracing accurate representations of about one hundred varieties of disease, most of 
thera the size of nature. Price, in extra cloth, $5 50. 
Also, the Text and Plates, bound in one handsome volume. Cloth, $10. 



No one treating skin diseases should be -without 
a copy of this standard woi'k. — Canada Lancet. 

We can safely recommend it to the profession at 
the best work on the subject now in existence ir 
the English language.— Medical Times and Gazette 

Mr. Wilson's volume is an excellent digest of the 
actual amount of knowledge of cutaneous diseases ; 
it includes almost every fact or opinion of importance 
connected with the anatomy and pathology of thf 
skin.— British and Foreign Medical Review. ■ 

Such a work as the one before us is a most capital 



ind acceptable help. Mr. Wilson has long been held 
is high authority in this department of medicine, and 
his book on diseases of the skin has long been re- 
garded as one of the best text-books extant on the 
subject. The present edition is carefully prepared, 
ind brought up in its revision to the present time in 
his edition we have also included the beautiful series 
of plates illustrative of the text, and in the last edi- 
tion published separately. There are twenty of these 
plates, nearly all of -them colored to nature, and ex- 
hibiting with great fidelity the various groups of 
diseases. — Cincinnati Lancet. 



JDY THE SAME AUTHOR. 

THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- 

eases op the skin. In one very handsome royal 12mo. volume. $3 50. 



J^ELIGAN [J. MOORE), M.D., M.R.I. A. 

PRACTICAL TREATISE ON DISEASES OF 

Fifth American, from the second and enlarged Dublin edition by T. 
In one neat royal 12mo. volume of 462 pages, cloth, $2 25. 



A 



THE SKIN. 

W. Belcher, M. D. 



Fully equal to all the requirements of students and 
young practitioners.— Dublin Med. Press. 

Of the remainder of the work we have nothing be- 
yond unqualified commendation to offer It is so far 
the most complete one of its size that has appeared, 
and for the student there can be none which can com- 
pare with it in practical value. All the late disco- 
veries in Dermatology have been duly noticed, and 1 
JfY THE SAME AUTHOR. 

ATLAS OF CUTANEOUS DISEASES. 



their value justly estimated; in a word, the work is 
fully up to the times, and is thoroughly stocked with 
most valuable information.— New York Med. Record, 
Jan. 15, 1867. 

The most convenient manual of diseases of th« 
skin that can be procured by the student. — Chicago 
Med. Journal, Dec. 1866. 



volume, with exquisitely colored plates, &c 

disease. Cloth, $5 50. 
The diagnosis of eruptive disease, however, under 
all circumstances, is very difficult. Nevertheless, 
Dr. Neligap has certainly, "as far as possible," given 
a faithful and accurate representation of this class of 
diseases, and there can be no doubt that these plates 
will be of great use to the student and practitioner in 
drawing a diagnosis as to the class, order, and species 
to which the particular case may belong. While 
looking over the "Atlas" we have been induced to 
examine also the "Practical Treatise," and we are 



In one beautiful quarto 

presenting about one hundred varieties of 



inclined to consider it a very superior work, com- 
bining accurate verbal description with sound views 
of the pathology and treatment of eruptive diseases. 
— Glasgow Med. Journal. 

A compend which will very much aid the practi- 
tioner in this difficult branch of diagnosis. Taken 
with the beautiful plates of the Atlas, which are re- 
markable for their accuracy and beauty of coloring, 
it constitutes a very valuable addition to the library 
of a practical man.— Buffalo Med. Journal. 



fflLLIER [THOMAS), M.D., 

«*•-*• Physician to the Skin Department of University College Hospital, &c. 

HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. 

Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations. 
Cloth, $2 25. 



We can couscientiously recommend it to the stu- 
dent ; the style is clear and pleasant to read, the 
matter is good, and the descriptions of disease, with 
the modes of treatment recommended, are frequently 
Illustrated with well-recorded cases. — London Med. 
Times and Gazette, April 1, 1865. 



It is a concise, plain, practical treatise on the vari- 
ous diseases of the skin ; just such a^work, indeed, 
as was much needed, both by medicail students and 
practitioners. — Chicago Medical Examiner, May, 
1865. 



A NDERSON {McCALL), M.D., 

-^*- Physician to the Dispensary for Skin Diseases, Glasgow, &c. 

ON THE TREATMENT OF DISEASES OF THE SKIN. With an 

Analysis of Eleven Thousand Consecutive Cases. In one vol. 8vo. $1. {Lately Published.) 

DEWEES ON THE PHYSICAL AND MEDTOAL 
TREATMENT OF CHILDREN. Eleventh edition. 
1 vol'. 8vo. of 648 pages. Cloth, $2 80. 



GUERSANT'S SURGICAL DISEASES OF INFANTS 
AND CHILDREN. Translated by R. J. Dungli- 
so.v, M.D. 1 vol. 8vo. Cloth, $2 50. 






Henry C. Lea's Publications— -(Diseases of Children). 31 



SJMITH {J. LE WIS), M. D., 

A3 Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N. T. 

A COMPLETE PRACTICAL TREATISE ON THE DISEASES OP 

CHILDREN. Second Edition, revised and greatly enlarged. In one handsome octavo 
volume of 742 pages, cloth, $5; leather, $fi. {Lately Published.) 
From the Preface to the Second Edition. 

In presenting to the profession the second edition of his work, the author gratefully acknow- 
ledges the favorable reception accorded to the first. He has endeavored to merit a continuance 
of this approbation by rendering the volume much more complete than before. Nearly twenty 
additional diseases have been treated of, among which may be named Diseases Incidental to 
Birth, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, 
and the various forms of Paralysis. Many new formulas, which experience has shown to be 
useful, have been introduced, portions of the text of a less practical nature have been con- 
densed, and other portions, especially those relating to pathological histology, have been 
rewritten to correspond with recent discoveries. Every effort has been made, however, to avoid 
an undue enlargement of the volume, but, notwithstanding this, and an increase in the size of 
the page, the number of pages has been enlarged by more than one hundred. 

227 West 49th Street, New York, April, 1872. 

The work will be found to contain nearly one-third more matter than the previous edition, and 
it is confidently presented as in every respect worthy to be received as the standard American 
text-book on the subject. 

Eminently practical as well as judicious in its We regard it as superior to any other single work 
teachings— Cincinnati Lancet and Obs., July, 1S72. on the diseases of infancy and childhood.— Detroit 

A standard work that leaves little to be desired.- *«>■ <* Med - ana Pharmacy, Aug. 1S72. 
Indiana Journal of Medicine, July, 1S72. We confess to increased enthusiasm in recommend- 

We know of no hook on this subject that we can ing this second edition.— St. Louis Med. and Surg. 
more cordially recommend to the medical student Journal, Aug. 1S72. 
and thepractiti'oner.— Cincinnati Clinic, June 29, '72. 



fJONDIE {D. FRANCIS), M. D. 

^ A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. 

Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- 
printed pages, cloth, $5 25 ; leather, $6 25. 
The present edition, which is the sixth, is fully up teachers. As a whole, however, the work is the best 
to the times in the discussion of all those points in the American one that we have, and in its special adapta- 
pathology and treatment of infantile diseases which fcion to American practitioners it certainly has no 
kave been brought forward by the Germau and French squal.— New York Med. Record, March 2, 186S. 



JKTEST {CHARLES), M.D., 

* * Physician to the Hospital for Sick Children, &c. 

LECTURES ON THE DISEASES OF INFANCY AND CHILD- 

HOOD. Fifth American from the sixth revised and enlarged English edition. In on e large 
and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. {Just Issued.) 

The continued demand for this work on both sides of the Atlantic, and its translation into Ger- 
man, French, Italian, Danish, Dutch, and Russian, show that it fills satisfactorily a want exten- 
sively felt by the profession. There is probably no man living who can speak with the authority 
derived from a more extended experience than Dr. West, and his work now presents the results of 
nearly 2000 recorded cases, and 600 post-mortem examinations selected from among nearly 40,000 
eases which have passed under his care. In the preparation of the present edition he has omitted 
much that appeared of minor importance, in order to find room for the introduction of additional 
matter, and the volume, while thoroughly revised, is therefore not increased materially in size. 

Of all the English writers on the diseases of chil- I living authorities in the difficult department of medi- 
dren, there is no one so entirely satisfactory to us as I cal science in which he is most widely known.— 
Dr. West. For years we have held his opinion as Boston Med. and Surg. Journal. 
judicial, and have regarded him as one of the highest | 



OF THE SAME AUTHOR. {Lately Issued.) 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 

HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- 
don, in March, 1871. In one volume, small 12mo., cloth, $1 00. 



&MITH (EUSTACE), M. D., 

Physician to the Northwest London Free Dispensary for Sick Children. 

A PRACTICAL TREATISE ON THE WASTING DISEASES OP 

INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged 
English edition. In one handsome octavo volume, cloth, $2 50. {Lately Issued.) 

This is in every way an admirable book. The 
modest title which the author has chosen for it scarce- 



ly conveys an adequate idea of the many subjects 
upon which it treats. Wasting is so constant an at- 
tendant upon the maladies of childhood, that a trea- 
tise upon the wasting diseases of children must neces 
sarily embrace the consideration of many affections 
of which it is a symptom ; and this is excellently well 
don9 by Dr. Smith. The book might fairly be de- 



scribed as a practical handbook of the common dis- 
eases of children, so numerous are the affections con- 
sidered either collaterally or directly. We are 
acquainted with no safer guide to the treatment of 
children's diseases, and few works give the insight 
into the physiological and other peculiarities of chil- 
dren that Dr. Smith's book does.— Brit. Med. Joum., 
April 8, 1871. 



22 



Henry C. Lea's Publications — (Diseases of Women). 



rpRE OBSTETRICAL JOURNAL. [Free of postage for 1875.) 

THE OBSTETRICAL JOURNAL of Great Britain and Ireland; 

Including Midwifery, and the Diseases op Women and Infants. With an American 
Supplement, edited by William F. Jenks, M.D. A monthly of about 80 octavo pages, 
very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 
cents each. 

Commencing with April, 1873, the Obstetrical Journal consists of Original Papers by Brit- 
ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; 
Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito- 
rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, &c. 
Collecting together the vast amount of material daily accumulating in this important and ra- 
pidly improving department of medical science, the value of the information which it pre- 
sents to the subscriber may be estimated from the character of the gentlemen who have already 
promised their support, including such names as those of Drs. Atthill, Robert Barnes, Henry 
Bennet, Thomas Chambers, Fleetwood Churchill, Matthews Duncan, Graily Hewitt, 
Braxton Hicks, Alfred Meadows, W. Irishman, Alex. Simpson, Tyler Smith, Edward J. 
Tilt, Spencer Wells, &c. &c. ; in short, the representative men of British Obstetrics and Gynae- 
cology. 

In order to render the Obstetrical Journal fully adequate to the wants of the American 
profession, each number contains a Supplement devoted to the advances made in Obstetrics and 
Gynaecology on this side of the Atlantic. This portion of the Journal is under the editorial 
charge of Dr. William F. Jenks, to whom editorial communications, exchanges, books for re- 
view, &c, may be addressed, to the care of the publisher. 

*#* Complete sets from the beginning can no longer be furnished, but subscriptions can com- 
mence with January, 1875, or with Vol. II., April, 1874. 









J'HOMAS [T.GAILLARD),M.D., 

Professor of Obstetrics, &c, in the College of Physicians and Surgeons, N. Y., &c. 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth 

edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 

800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Now Ready.) 

The author has taken advantage of the opportunity afforded by the call for another edition of 

this work to render it worthy a continuance of the very remarkable favor with which it has been 

received. Every portion has been subjected to a conscientious revision, and no labor has been 

spared to make it a complete treatise on the most advanced condition of its important subject. 

A few notices of the previous editions are subjoined : — 

No general practitioner can afford to be without 
it.— St. Louis Med. mnd Surg. Journal, May, 1S72. 



Professor Thomas fairly took the Profession of the 
United States by storm when his book first made its 
appearance early in 1S6S. Its reception was simply 
enthusiastic, notwithstanding a few adverse criti- 
cisms from our transatlantic brethren, the first large 
edition was rapidly exhausted, and in six months a 
second one was issued, and in two years a third one 
was announced and published, and we are now pro- 
mised the fourth. The popularity of this work was 
not ephemeral, and its success was unprecedented in 
the annals of American medical literature. Six years 
is a loug period in medical scientific research, but 
Thomas's work on "Diseases of Women" is still the 
leading native production of the United States. The 
order, the matter, the absence of theoretical disputa- 
tiveness, the fairness of statement, and the elegance 
of diction, preserved throughout the entire rauge of 
the book, indicate that Professor Thomas did not 
overestimate his powers when he conceived the idea 
and executed the work of producing a new treatise 
upon diseases of women. — Prof. Pallet, in Louis- 
ville Med. Journal, Sept. 1874. 

Briefly, we may say that we know of no book 
which so completely and concisely represents the 
present state of gynaecology ; none so full of well- 
digested and reliable teaching ; none which bespeaks 
an author more apt in research and abundant in re- 
sources.—^. Y Med. Record, May 1, 1872. 

We should not be doing our duty to the profession 
did we not tell those who are unacquainted with the 
book, how much it is valued by gynaecologists, and 
how it is in many respects one of the best text-books 
on the subject we possess in our language. We have 
no hesitation in recommending Dr. Thomas's work as 
one of the most complete of its kind ever published. 
It should be in the possession of every practitioner 
for reference and for study.— London Lancet, April 
27, 1872. 

We are free to say that we regard Dr. Thomas the 
best American authority on diseases of women. — 
Cincinnati Lancet and Observer, May, 1S72. 



as 



Its able author need not fear comparison between 
it and any similar work in the English language; 
nay more, as a text-boek for students and as a guide 
for practitioners, we believe it is unequalled. If 
either student or practitioner can get but one book 
on diseases of women, that book should be ;, Thoma8." 
— Araer. Jour. Med. Sciences, April, ' 872. 

To students we unhesitatingly recommend it 
the best text-book on diseases of females extant 
St Louis Med. Reporter, June, 1869. 

Of all the army of books tha,t nave appeared of late 
years, on the diseases of the uterus and its appendages, 
we know of none that is so clear, comprehensive, and 
practical as this of Dr. Thomas', or one thatwe should 
more emphatically recommend to the young practi- 
tioner, as his guide. — California Med. Gazette, June, 
1869. 

It would be superfluous to give an extended review 
of what is now firmly established as the American 
text-book of Gynaecology.— N. 1. Med. Gazette, July 
17, 1S69. 

This is a new and revised edition of a work which 
we recently noticed at some length, and earnestly 
commended to the favorable attention of our readers. 
The fact that, in the short space of one year, this 
second edition makes its appearance, shows that the 
general judgment of the profession has largely con- 
flrraed the opinion we gave at that time.— Cincinnati 
Lancet, Aug. 1869. 

It is so short a time since we gave a full review of 
the first edition of this book, that we deem it only 
necessary now to call attention to the second appear- 
ance of the work. Its success has been remarkable, 
and we can only congratulate the author on the 
brilliant reception his book has received.— N. Y. MeA. 
Journal, April, 1869. 



Henry C. Lea's Publications — (Diseases of Women). 



23 



TJOBGE {HUGH L.), M.D., 

S.J. Emeritus Professor of Obstetrics, &c, in the University of Pennsylvania. 

ON DISEASES PECULIAR TO WOMEN; including Displacements 

of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
one heautifully printed octavo volume of 531 pages, cloth, $4 50. 
From Prof. W. H. Btford, of the Rush Medical f ;hat which speaks of the mechanical treatment of dis' 



College, Chicago. 

The book bears the impress of a master hand, and 
must, as its predecessor, prove acceptable to the pro- 
fession. In diseases of women Dr. Hodge has estab- 
lished a school of treatment that has become world- 
wide in fame. 

Professor Hodge's work is truly an original one 
from beginning to end, consequently no one can pe- 
ruse its pages without learning something new. The 
book, which is by no means a large one. is divided into 
two grand sections, so to speak : first, that treating of 
the nervous sympathies of the uterus, and, secondly, 



placements of that organ. He is disposed, as a non- 
believer in the frequency of inflammations of the 
uterus, to take strong ground against many of the 
highest authorities in this branch of medicine, and 
the arguments which he offers in support of his posi- 
tion are. to say the least, well put. Numerous wood- 
cuts adorn this portion of the work, and add incalcu- 
lably to the proper appreciation of the variously 
shaped instruments referred to by our author. As a 
contribution to the study of women's diseases, it is of 
great value, and is abundantly able to stand on iU 
own merits.— N. ¥. Medical Record, Sept. 15, 1868. 



TXTEST (CHARLES), 31. D. 

LECTURES ON THE DISEASES OF WOMEN. Third American, 

from the Third London edition. In one neat octavo volume ofahout 550 pages, cloth, 
$3 75 ; leather, $4 75. 
As a -writer. Dr. West stands, in our opinion, se- seeking truth, and one that will convince the student 
cond only to Watson, the "Macaulay of Medicine;' that he has committed himself to a candid, safe, and 



he possesses that happy faculty of clothing instruc 
tion in easy garments : combining pleasure witt 
profit, he leads his pupils, in spite of the ancient pro- 
verb, along a royal road to learning. His work is one 
which will not satisfy the extreme on either side, but 
it is one that will please the great majority who are 



valuable guide. —N. A. Med.-Chirtirg Review. 

We have to say of it, briefly and decidedly, that it 
is the best work "on the subie'ct in any language, and 
that it stamps Dr. West as the facile princeps of 
British obstetric authors.— Edinburgh Med. Journal. 



TfARNES (ROBERT), M. D., F.R. C.P., 

J-* Obstetric Physician to St. Thomas's Hospital, &c. 

A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
CAL DISEASES OF WOMEN. In ™» hnT^some octavo volume of about 800 pages, with 
169 illustrations. Cloth. $"5 00; leather, $6 00. (Just Issued.) 

The very complete scope of this volume and the manner in which it has heen filled out, may 
be seen by the subjoined Summary of Contents. 

Introduction. Chapter I. Ovaries ; Corpus Luteum. II. Fallopian Tubes. III. Shape of 
Uterine Cavity. IV. Structure of Uterus. V. The Vagina. VI. Examinations and Diagnosis. 
VII. Significance of Leucorrhcea. VIII. Discharges of Air. IX. Watery Discharges. X. Puru- 
lent Discharges. XI. Hemorrhagic Discharges. XII Significance of Pain. XIII. Significance 
of Dyspareunia. XIV. Significance of Sterility. XV. Instrumental Diagnosis and Treatment. 
XVI. Diagnosis by the Touch, the Sound, the Speculum. XVII. Menstruation and its Disor- 
ders. XVIII. Amenorrhoea. XIX. Amenorrhcea (continued). XX. Dysmenorrhcea. XXI. 
Ovarian Dysmenorrhea. &c. XXII. Inflammatory Dysmenorrhoea. XXItl. Irregularities of 
Change of Life. XXIV. Relations between Menstruation and Diseases. XXV. Disorders of Old 
Age. XXVI. Ovary, Absence and Hernia of. XXVII. Ovary, Hemorrhage, &c, of. XXVIII. 
Ovary, Tubercle. Cancer, &c, of. XXIX. Ovarian Cystic Tumors. XXX. Dermoid Cvsts of 
Ovary. XXXI. Ovarian Tumors, Prognosis of. XXXII. Diagnosis of Ovarian Tumors. XXXIII. 
Ovarian Cysts, Treatment of. XXXIV. Fallopian Tubes. Diseases of. XXXV. Broad Liga- 
ments, Diseases of. XXXVI. Extra-uterine Gestation. XXXVII. Special Pathology of Ute 
rus. XXXVIII. General Uterine Pathology. XXXIX. Alterations of Blood .Supply. XL. 
Metritis. Endometritis, &c. XLI. Pelvic Cellulitis and Peritonitis, &c. XLII. Hasniatocele, &c 
XLIII. Displacements of Uterus. XLIV. Displacements (continued). XLV. Retroversion and 
Retroflexion. XLVI. Inversion. XLVII. Uterine Tumors. XLVIII. Polypus Uteri. XLIX. 
Polypus Uteri (continued). L. Cancer. LI. Diseases of Vagina. LII. Diseases of the Vulva. 



Embodying the long experience and personal obser- 
vation of one of the greatest of living teachers in dis- 
eases of women, it seems pervaded by the presence 
of tbe author, who speaks directly to the reader, and 
speaks, too, as one having authority. And yet, not- 
withstanding tbis distinct personality, there is noth- 
ing narrow as to time, place, or individuals, in the 
views presented, and in the instructions given; Dr. 
Barnes has been an attentive student, not only of Eu- 
ropean, but also of American literature, pertaining to 
diseases of females, and enriched\his own experience 
by treasures thence gathered : he seems as familiar, 
for example, with the writings of Sims, Emmet, Tho- 



mas, and Peaslee, as if these eminent men were his 
countrymen and colleagues, and gives them a credit 
which must be gratifying to every American physi- 
cian. — Am Journ. Med. Sci., April, 1S74. 

Throughout the whole book it is impossible not to 
feel that the author has spontaneously, conscientious- 
ly, and fearlessly performed his task. He goes direct 
to the point, and* does not loiter on the way to gossip- 
or quarrel with other authors. Dr. Barnes's book 
will be eagerly read all over the world, and will 
everywhere be admired for its comprehensiveness, 
honesty of purpose, and ability — The Ohstet. Journ. 
of Great Britain and Ireland, March, 1S74. 



CHURCHILL ON THE PUERPERAL FEVER AND 
OTHER DISEASES PECULIAR TO WOMEN. 1 vol. 
8vo., pp. 450, cloth. $2 50. 

MEIGS ON WOMAN: HER DISEASES AND THEIR 
REMEDIES. A Series of Lectures to his Class. 
Fourth and Improved Edition. 1 vol. 8vo., over 
700 pages, cloth, $5 00 ; leather, *6 00. 

MEIGS ON THE NATURE, SIGNS, AND TREAT- 
MENT OF CHILDBED FEVER. 1 vol. 8vo., pp. 
365, cloth. $2 00. 



ASHWELL'S PRACTICAL TREATISE ON THE DIS- 
EASES PECULIAR TO WOMEN. Third American, 
from the Third and revised London edition. 1 vol. 
8vo., pp. 528, cloth. $3 50. 

DEWEES'S TREATISE ON THE DISEASES OF FE- 
MALES. With illustrations. Eleventh Edition, 
with the Author's last improvements and correc- 
tions. In one octavo volume of 536 pages, with 
plates, cloth. $3 00. 



24 



Henry C. Lea's Publications— (Midwifery). 



JTODOE {HUGH L.), M.D., 

■*-*• Emeritus Professor of Midwifery, &c, in the University of Pennsylvania, &c. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 
trated with large lithographic plates containing one hundred and fifty-nine figures from 
original photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 



The work of Dr. Hodge is something more than 
simple presentation of his particular views in the de- 
partment of Obstetrics ; it is something more than an 
ordinary treatise on midwifery ; it is, in fact, a cyclo- 
paedia of midwifery. He has aimed to embody in a 
single volume the whole science and art of Obstetrics. 
Au elaborate text is combined with accurate and va- 
ried pictorial illustrations, so that no fact or principle 
Is left unstated or unexplained. — Am. Med. Times, 
Sept. 3, 1864. 

We should like to analyze the remainder of this 
excellent work, but already has this review extended 
beyond our limited space. We cannot conclude this 
notice without referring to the excellent finish of the 
work. In typography it is not to be excelled; the 
paper is superior to what is usually afforded by our 
American cousins, quite equal to the best of English 
books. The engravings and lithographs are most 
beautifully executed. The work recommends itself 
for its originality, and is in every way a most valu- 
able addition to those on the subject of obstetrics. — 
Canada Med. Journal, Oct. 1864 

It is very large, profusely and elegantly illustrated, 
and is fitted to take its place near the works of great 
obstetricians. Of the American works on the subject 
It is decidedly the best.— Edinb. Med. Jour., Dec. '64. 

%*% Specimens of the plates and letter-press will be forwarded to any address, free by maiS, 
on receipt of six cents in postage stamps. 

JUNNER {THOMAS H), M.D. 
ON THE SIGNS AND DISEASES OF PREGNANCY. First American 

from the Second and Enlarged English Edition. With' four colored plates and illustrations 
on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 
The very thorough revision the work has undergone 

has added greatly to its practical value, andincreased 

materially its efficiency as a guide to the student and 



We have examined Professor Hodge's work with 
great satisfaction ; every topic is elaborated most 
fully. The views of the author are comprehensive, 
and concisely stated. The rules of practice are judi- 
cious, and will enable the practitioner to meet every 
emergency of obstetric complication with confidence. 
— Chicago Med. Journal, Aug. 1864. 

More time than we have had at our disposal since 
we received the great work of Dr. Hodge is necessary 
to do it justice. It is undoubtedly by far the most 
original, complete, and carefully composed treatise 
on the principles and practice of Obstetrics which has 
ever been issued from the American press. — Pacific 
Med. and Surg. Journal, July, 1864. 

We have read Dr. Hodge's book with great plea- 
sure, and have much satisfaction in expressing our 
commendation of it as a whole. It is certainly highly 
instructive, and in the main, we believe, correct. The 
great attention which the author has devoted to the 
mechanism of parturition, taken along with the con- 
clusions at which he has arrived, point, we think, 
conclusively to the fact that, in Britain at least, the 
doctrines of Naegele have been too blindly received. 
—Glasgow Med. Journal, Oct. 1864. 



to the young practitioner.— Am. Journ. Med. Set, 
April, 1868. 

With the immense variety of subjects treated of 
and the ground which they are made to cover, the im- 
possibility of giving an extended review of this truly 
remarkable work must be apparent. We have not a 
single fault to find with it, and most heartily com- 
mend it to the careful study of every physician who 
would not only always be sure of his diagnosis of 



pregnancy, but always ready to treat all the nume- 
rous ailments that are, unfortunately for the civilized 
women of to-day, so commonly associated with the 
function.— N. T. Med. Record, March 16, 1868. 

We recommend obstetrical students, young and 
old, to have this volume in their collections. It con- 
tains not only a fair statement of the signs, symptoms, 
and diseases of pregnancy, but comprises in addition 
much interesting relative matter that is not to be 
found in any other work that we can name. — Edin- 
burgh Med Journal, Jan. 1868. 



G WAYNE {JOSEPH GRIFFITHS), M. D., 

*^ Physician- Accoucheur to the British General Hospital, &c. 

OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised 
London Edition, with Additions by E. R. Hutchins, M. D. With Illustrations. In one 
neat 12mo. volume. Cloth, $1 25. {Lately Issued.) 
*** See p. 3 of this Catalogue for the terms on which this work is offered as a premium to 
subscribers to the "American Journal op the Medical Sciences." 



it is really a capital little compendium of the sub- 
ject, and we recommend young practitioners to buy it 
and carry it with them when called to attend cases of 
labor. They can while away the otherwise tedious 
hours of waiting, and thoroughly fix in their memo- 
ries the most important practical suggestions it con- 
tains. The American editor has materially added by 
his notes and the concluding chapters to the com- 
pleteness and general value of the book. — Chicago 
Med. Journal, Feb. 1870. 

The manual before us containsin exceedingly small 
compass — small enough to carry in the pockei — about 
all there is of obstetrics, condensed into a nutshell of 
Aphorisms. The illustrations are well selected, and 
serve as excellent reminders of the conduct of labor — 
regular and diflicult.— Cincinnati Lancet, April, '70. 

•Wii s is a mostadmirable lit tie work, and completely 



answers the purpose. It is not only valuable for 
young beginners, but no one who is not a proficient 
in the art of obstetrics should be without it, because 
it condenses all that is necessary to know for ordi- 
nary midwifery practice. We commend the book 
most favorably. — St. Louis Med. and Surg. Journal, 
Sept. 10, 1870. 

A studied perusal of this little book has satisfied 
us of its eminently practical value. The object of the 
work, the author says, in his preface, is to give the 
student a few brief and practical directions respect- 
ing the management of ordinary cases of labor ; and 
also to point out to him in extraordinary cases wheD 
and how he may act upon his own responsibility, and 
when he ought to send for assistance. — N. ¥. Medical 
Journal, May, 1870. 



w 



'INCKEL {F.), 

Professor and Director of the Gynaecological Clinic in the University of Rostock. 

A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- 

MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of 
the author, from the Second German Edition, by James Read Chadwick, M.D. In one 
ootavo volume. (Preparing.) 



Henry. C. Lea's Publications— {Midwifery). 



25 



J^EISHMAN { WILLIAM), M.I)., 

Regius Professor of Midwifery in the University of Glasgow &c 

A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 

PREGNANCY AND THE PUERPERAL STATE. In one large and very Indsom oc- 

^^^^rds^^uZ^T^ and eighty - tw ° m — - <*>*■ 

This is one of a most complete and exhf 



istive cha- 
racter. We have gone carefully through it, and there 
is no subject in Obstetrics which ha* not been con- 
sidered well and fully. The result is a work, not 
only admirable as a text-book, but valuable as a work 
of reference to the practitioner in the various emer- 
gencies of obstetric practice. Take it all in all, we 
have no hesitation in saying that it is in our judgment 
the best English work on the subject.— London Lan- 
cet, Aug. 23, 1S73. 

The work of Leishman gives an excellent view of 
modern midwifery, and evinces its author's extensive 
acquaintance with British and foreign literature ; and 
not only acquaintance with it, but wholesome diges- 
tion and sound judgment of it. He has, withal, a 
manly, free style, and can state a difficult and compli- 
cated matter with remarkable clearness and brevity. 
— Edin. Med. Joum., Sept. 1S73. 

The author has succeeded in presenting to the pro- 
fession an admirable treatise, especially in its practi- 
cal aspects ; one which is, in general, clearly written, 
and sound in doctrine, and one which cannot fail to 
add to his already high reputation. In concluding 
our examination of this work, we cannot avoid again 
saying that Dr. Leishman has fully accomplished 
that difficult task of presenting a good text-book upon 
obstetrics. We know none better for the use of the stu- 
dent or junior practitioner.— Am. Practitioner, Mar 
1874. 

It proposes to offer to practitioners and students 



A Complete System of the Midwifery of the Present 
Day, and well redeems the promise. In all that 
relates to the subject of labor, the teaching is admi- 
rably clear, concise, and practical, representing not 
alone British practice, but the contributions of Con- 
tinental and American schools.— N. Y. Med. Record 
March 2, 1S74. ' 

The work of Dr. Leishman is, in many respects, 
not only the best treatise on midwifery that we have 
seen, but one of the best treatises on any medical sub- 
ject that has been published of late years.— Lond 
Practitioner, Feb. 1874. 

It was written to supply a desideratum, and we will 
be much surprised if it does not fulfil the purpose of 
its author. Taking it as a whole, we know of no 
work on obstetrics by an English author in which the 
student and the practitioner will find the information 
so clear and so completely abreast of the present state 
of our knowledge on the subject.- Glasgow Med. 
Joum., Aug. 1S73. 

Dr. Leishman's System of Midwifery, which has 
only just been published, will go far to supply the 
want which has so long been felt, of a reallv good 
modern English text-book. Although large, as is in- 
evitable in a work on so extensive a subject, it is so 
well and clearly written, that it is never wearisome 
to read. Dr. Leishman's work may be confidently 
recommended as an admirable text-book, and is sure 
to be largely used.— Lond. Med. Record, Sept. 1S73 



J^AMSBOTHAM {FRANCIS H.), M.D. 

T ?ine P and N su^ E v S - A ^ D PRACTI CE OF OBSTETRIC MEDL 

CINE AND aURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. V. kIating M D 
Processor of Obstetrics Ac., in the Jefferson Medical College, Philadelphia. In one largo 

S^d, wT e ™p; naI ^? vo lume of 650 pageS; Bt ! bound in ? eath g 

a?/!,' ^ffty-fo™^^ Plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00. 6 

To the physician's library it is indispensable, while 
to the student, as a text-book, from which to extract 



We will only add that the student will learn from 
It all he need to know, and the practitioner will find 
it, as a book of reference, surpassed by none other — 
Stethoscope. 

The character and merits of Dr. Ramsbotham's 
work are so well known and thoroughly established 
that comment is unnecessary and praise superfluous 

The illnRtratinno rrrlii/iV, a™ v..,™„.,„ j , 



"*«,v uviumciii 10 uiiiieuessary ana praise superfluous. 

The illustrations, which are numerous and accurate' , 

are executed in the highest style of art. We cannot | tTis'™Ywm7 ff o^^^ 



~i oA D m lC u 1U (.lie uiguest scyie or art. vve cannot 
too highly recommend the work to our readers.— St 
Louis Med. and Surg. Journal. 



,u " uc otuucMi, a,* a, texi-oooK, irom wnich to extract 
the material for laying the foundation of an education 
on obstetrical science, it has no superior.— Ohio Med 
and Surg. Journal. 

When we call to mind the toil we underwent in 
acquiring a knowledge of this subject, we cannot but 
envy the student of the present day the aid which 
this work will afford him. — Am. Jmi.r nt' +h« -m»a 



Sciences. 



(JHURCHILL {FLEETWOOD), M.D., M.R.I A. 

ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 

bvT^rS t n 6 f0Mth "™ d a f d enla rged London edition. With notes and additions 
&?">'* w-*S° WD ?' *[' ?■' ^ th . 0r ° f a " Practi ^l Treatise on the Diseases of Chil- 
J 1 *°' With one hundred and ninety-four illustrations. In one very handsome octavo 
volume of nearly 700 large pages. Cloth, $4 00 ; leather, $5 00. 

quainted can compare favorably with this, in re- 
spect to the amount of material which has been gath- 
ered from every source.— Boston Med. and Sura 
Journal. 

There is no better text-book for students, or work 



These additions render the work still more com 
plete and acceptable than ever; and we can com- 
mend it to the profession with great cordiality and 
pleasure.— Gin linnati Lancet. 

Few work? on this branch of medical science are 
aqual to it, certainly none excel it, whether in regard 
to theory or practice— Brit. Am. Journal. 

No treatise on obstetrics with which we are ac 



^^.ic i0 U.U uottw ihal-uuuh ior stuaents, or worJs 
of reference and study for the practising physician 
than this. It should adorn and enrich every medical 
library.— Chicago Med. Journal. 



M °i^ G 2^5 T ' S EXPOSITION OF THE SIGNS 
AND SYMPTOMS OF PREGNANCY. With two 
exquisite colored plates, and numerous wood-cuts 
In lvol. 8vo., of nearly 600 pp., cloth. $3 75. 



SIGBY'S SYSTEM OF MIDWIFERY. With Notes 
and Additional Illustrations. Second American 
edition. One volume octavo, cloth, 422 pases. 
$2 50. *— e 



26 



Henry C. Lea's Publications— (Surgery), 



flROSS {SAMUEL D.), M.D., 

^* Professor of Surgery in the Jefferson Medical College of Philadelphia. 

A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 

and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, 
carefully revised, and improved. In two large and beautifully printed imperial octavo vol- 
umes of about 2300 pages, strongly bound in leather, with raised bands, $15. (Just Issued.) 
The continued favor, shown by the exhaustion of successive large editions of this great work, 
proves that it has successfully supplied a want felt by American practitioners and students. In the 
present revision no pains have been spared by the author to bring it in every respect fully up to 
the day. To effect this a large part of the work has been rewritten, and the whole enlarged by 
nearly one-fourth, notwithstanding which the price has been kept at its former very moderate 
rate. By the use of a close, though very legible type, an unusually large amount ot matter is 
condensed in its pages, the two volumes containing as much as four or five ordinary octavos. 
This, combined with the most careful mechanical execution, audits very durable binding, renders 
it one of the cheapest works accessible to the profession. Every subject properly belonging to the 
domain of surgery is treated in detail, so that the student who possesses this work may be said to 
have in it a surgical library. A few notices of the previous edition are subjoined : — 

hesitation in pronouncing it without a rival in our 



It must long remain the most comprehensive work 
on th.ii important part of medicine. — Boston Medical 
gical Journal, March 23, 1865. 

We have compared it with most of our standard 
ivorks, such as those of Erichsen, Miller, Fergusson, 
Syme, and others, and we must, in justice to our 
author, award it the pre-eminence. As a work, com- 
plete in almost every detail, no matter how minute 
or trifling, and embracing every subject known in 
the principles and practice of surgery, we believe it 
stands without a rival. Dr. Gross, in his preface, re- 
marks "my aim has been to embrace the whole do- 
main of surgery, and to allot to every subject its 
legitimate claim to notice;" and, we assure our 
readers, be has kept his word. It is a work which 
we can most confidently recommend to our brethren, 
for its utility is becoming the more evident the longer 
It is upon the shelves of our library.— Canada Med. 
Journal, September, 1865. 

The first two editions of Professor Gross' System of 
Surgery are so well known to the profession, and so 
highly prized, that it would be idle for us to speak in 
praise of this work.— Chicago Medical Journal, 
September, 1865. 

We gladly indorse the favorable recommendation 
of the work, both as regards matter and style, which 
we made when noticing its first appearance.— British 
and Foreign Medico-Chirurgical Review, Oct. 1865. 

The most complete work that has yet issued from 
the press on the science and practice of surgery.— 
London Lancet. 

This system of surgery is, we predict, destined to 
take a commanding position in our surgical litera- 
ture, and be the crowning glory of the author's well 
earned fame. As an authority on general surgical 
subjects, this work is long to occupy a pre-eminent 
place, not only at home, but abroad. We have no 

BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON 

AIR-PASSAGES. In 1 vol. 8vo 



language, and equal to the best systems of surgery in 
any language. — N. ¥. Med. Journal. 

Not only by far the best text-book on the subject, 
as a whole, within the reach of American students, 
but one which will be much more than ever likely 
to be resorted to and regarded as a high authority 
abroad. — Am. Journal Med. Sciences, Jan. 1865. 

The work contains everything, minor and major, 
opei'ative and diagnostic, including mensuration and 
examination, venereal diseases, and uterine manipu- 
lations and operations. It is a complete Thesaurus 
of modern surgery, where the student and practi- 
tioner shall not seek in vain for what they desire.— 
San Francisco Med. Press, Jan. 1865. 

Open it where we may, we find sound practical in- 
formation conveyed in plain language. This book is 
no mere provincial or even national system of sur- 
gery, but a work which, while very largely indebted 
to the past, has a strong claim on the gratitude of the 
future of surgical science. — Edinburgh Med. Journal, 
Jan. 1865. 

A glance at the work is sufficient to show that the 
author and publisher have spared no labor in making 
it the most complete "System of Surgery" ever pub- 
lished in any country. — St. Louis Med. and Surg. 
Journal, April, 1865. 

A system of surgery which we think unrivalled in 
our language, and which will indelibly associate his 
name with surgical science. And what, in our opin- 
ion, enhances the value of the work is that, while the 
practising surgeon will find all that he requires in it, 
it is at the same time one of the most valuable trea- 
tises which can be put into the hands of the student 
seeking to know the principles and practice of thit 
branch of the profession which he designs subse- 
quently to follow.— The Brit. Am.Journ., Montreal. 



FOREIGN BODIES IN THE 

with illustrations, pp. 468, cloth, $2 75. 



bKEY'S OPEKATIYE SURGERY. In 1 vol. 8vo. 

cloth, of over 650 pages ; with about 100 wood-cats. 

$3 25. 
COOPER'S LECTURES ON THE PRINCIPLES AN© 

Pu actice op Surgery. In 1 vol. 8vo. cloth, 750 p. $2. 



GIBSON'S INSTITUTES AND PRACTICE OF 8UR- 
gert. Eighth edition, improved and altered. With 
thirty-four plates. In two handsome octavo vol- 
umes, aboutlOOOpp., leather, raised bandb. $6 60. 



M 



1LLER {JAMES), 

Late Professor of Surgery in the University of Edinburgh, &c. 

PRINCIPLES OF SURGERY. Fourth American, from the third and 

revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with 
two hundred and forty illustrations on wood, cloth, $3 75. 

DY THE SAME AUTHOR. 

THE PRACTICE OF SURGERY. Fourth American, from the last 

Edinburgh edition. Revised by the American editor. Illustrated by three hundred and 
sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, cloth, 

$3 75. _____ 

QARGENT (F. W.), M.D. 
® ON BANDAGING AND OTHER OPERATIONS OF MINOR 

SURGERY, New edition, with an additional chapter on Military Surgery. One handsome 
royal l2mo. volume, of nearly 400 pages, with 184 wood-outs. Cloth, $1 75. 



Henry C. Lea's Publications — (Surgery). 2T 

ASEHURST {JOHN, Jr.), M.D., 

Surgeon to the Episcopal Hospital, Philadelphia. 

THE PRINCIPLES AND PRACTICE OF SURGERY. In one 

very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, 
cloth, $6 50; leather, raised bands, $7 50. {Lately Published.) 

The object of the author has been to present, within as condensed a compass as possible, a 
complete treatise on Surgery in all its branches, suitable both as a text-book for the student and 
a work of reference for the practitioner. So much has of late years been done for the advance- 
ment of Surgical Art and Science, that there seemed to be a want of a work which should present 
the latest aspects of every subject, and which, by its American character, should render accessible 
to the profession at large the experience of the practitioners of both hemispheres. This has been 
the aim of the author, and it is hoped that the volume will be found to fulfil its purpose satisfac- 
torily. The plan and general outline of the work will be seen by the annexed 

CONDENSED SUMMARY OF CONTENTS. 

Chapter I. Inflammation. II. Treatment of Inflammation. III. Operations in general : 
Anaesthetics. IV. Minor Surgery. V. Amputations. VI. Special Amputations. VII. Effects 
of Injuries in General : Wounds. VIII. Gunshot Wounds. IX. Injuries of Bloodvessels. X. 
Injuries of Nerves, Muscles and Tendons, Lymphatics, Bursae, Bones, and Joints. XI. Fractures. 
XII. Special Fractures. XIII. Dislocations. XIV. Effects of Heat and Cold. XV. Injuries 
of the Head. XVI. Injuries of the Back. XVII. Injuries of the Face and Neck. XVIII. 
Injuries of the Chest. XIX. Injuries of the Abdomen and Pelvis. XX. Diseases resulting from 
Inflammation. XXI. Erysipelas. XXII. Pyaemia XXIII. Diathetic Diseases : Struma (in- 
cluding Tubercle and Scrofula); Rickets. XXIV. Venereal Diseases ; Gonorrhoea and Chancroid. 
XXV. Venereal Diseases continued : Syphilis. XXVI. Tumors. XXVII. Surgical Diseases of 
Skin, Areolar Tissue, Lymphatics, Muscles, Tendons, and Bursae. XXVIII. Surgical Disease 
of Nervous System (including Tetanus). XXIX. Surgical Diseases of Vascular System (includ- 
ing Aneurism). XXX. Diseases of Bone. XXXI. Diseases of Joints. XXXII. Excisions. 
XXXIII. Orthopaedic Surgery. XXXIV. Diseases of Head and Spine. XXXV. Diseases of the 
Eye. XXXVI. Diseases of the Ear. XXXVII. Diseases of the Face and Neck. XXXVIII. 
Diseases of the Mouth, Jaws, and Throat. XXXIX. Diseases of the Breast. XL. Hernia. XLI. 
Special Herniae. XLII. Diseases of Intestinal Canal. XLIII. Diseases of Abdominal Organs, 
and various operations on the Abdomen. XLIV. Urinary Calculus. XLV. Diseases of Bladder 
and Prostate. XLVI. Diseases of Urethra. XLVII. Diseases of Generative Organs. Index. 

Its author has evidently tested the writings and j Indeed, the work as a whole must be regarded as 
experiences of the past and present in the crucible an excellent and concise exponent of modern sur- 
of a careful, analytic, and honorable mind, and faith- gery, and as such it will be found a valuable text- 
fnlly endeavored to bring his work up to the level of book for the student, and a useful book of reference 



the highest standard of practical surgery. He is j for the general practitioner. — N. Y. Med. Joitrnal 
frank and definite, and gives us opinions, and gene- 
rally sound ones, instead of a mere resume of the 
opinions of others. He is conservative, but not hide 



bound by authority. His style is clear, elegant, and 
scholarly. The wcrk is an admirable tex-tbook, and 
a useful book of reference It is a credit to American 
professional literature, and one of the first ripe fruits 
of the soil fertilized by the blood of our late unhappy 
war.— iV. Y. Med. Record, Feb. 1, 1872. 



Feb. 1S72. 
It gives us great pleasure to call the attention of the 



profession to this excellent work. Our kno wledge of 
its talented and accomplished author led us to expect 
from him a very valuable treatise upon subjects to 
which he has repeatedly given evidence of having pro- 
fitably devoted much time and labor, and we are in no 
way disappointed.— Phila. Med. Times, Feb. 1, 1872. 



PIRRIE { WILLIAM), F. R. S. E., 
Professor of Surgery in the University of Aberdeen. 

THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by 

John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the 
Pennsylvania Hospital, &c. In one very handsome octavo volume of 780 pages, with 316 
illustrations, cloth, $3 75. 



H 



AMILTON {FRANK H.), M.D., 

Professor of Fractures and Dislocations, &c, in Bellevue Hosp. Med. College, New York. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
TIONS. Fourth edition, thoroughly revised. In one large and handsome octavo volume 
of nearly 800 pages, with several hundred illustrations. Cloth, $5 75; leather, $6 75. 



It is not, of course, our intention to review in ex- 
tenso, Hamilton on "Fractures and Dislocations." 
Eleven years ago such review might not have been 
out of place ; to-day the work is an authority, so well, 
so generally, and so favorably known, that it only 
remains for the reviewer to say that a new edition is 
just out, and it is better than either of its predeces- 
sors. — Cincinnati Clinic, Oct. 14, 1S71. 

Undoubtedly the best work on Fractures and Dis- 
locations in the English language. — Cincinnati Med. 
Repertory, Oct. 1871. 

We have once more before us Dr. Hamilton's admi- 



rable treatise, which we have always considered the 
most complete and reliable work on the subject. As 
a whole, the work is without an equal in the litera- 
ture of the profession. — Boston Med. and Surg. 
Journ., Oct. 12, 1S71. 

It is unnecessary at this time to commend the book, 
except to such as are beginners in the study of this 
particular branch of surgery. Every practical sur- 
geon in this country and abroad knows of it as a most 
trustworthy guide, and one which they, in common 
with us, would unqualifiedly recommend as the high- 
est authority in any language. — N. Y. Med. Record, 
Oct. 16, 1871. 



28 Henry C. Lea's Public ati onb— (Surgery). 

&RICHSEN {JOHN E.), r •■ ^ 

JOJ Professor of Surgery in University College, London, etc. 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 

rical Injuries, Diseases, and Operations. Revised by the author from the Sixth and 
enlarged Eng ish Edition. Illustrated by over seven hundred engravings on wood. In 
two large and beautiful octavo volumes of over 1700 pages, cloth, $9 00 ; leather, $11 00. 
{Lately Issued.)' 

Author's Preface to the New American Edition. 
.« The favorable reception with which the « Science and Art of Surgery' has been honored by the 
Surgical Profession in the United States of America has been not only a source of deep gratifica- 
don and of just pride to me, but has laid the foundation of many professional friendships that 
are amonest the agreeable and valued recollections of my life. .**..* a „ „«,«,„ 

» W f endeavored to make the present edition of this work more deserving than its predecessors 
of tL i^vo ttThas been accorded to them. In consequence of delays ^at have unavoidably 
occurred in the publication of the Sixth British Edition, time has been afforded to »e t0 »dd t0 th" 
one several paragraphs which I trust will be found to increase the practical value of the woik. 
London, Oct. 1872. , 

On no former edition of this work has the author bestowed more pains to render it a complete and 
sat factory expo s ition of British Surgery in its modern aspects. Every portion has been sedu- 
lou«lv revved and a large number of new illustrations have been introduced. In addition to the 
ma tri thu adS d to the English edition, the author has furnished for ^the American edition such 
mfter a ns has accumulated since the passage of the sheets through the press in London, so that 
Se work as now presented to the American profession, contains his latest views and experience. 
The increase in the size of the work has seemed to render necessary its division into two vol- 
umes Grea^ care has been exercised in its typographical execution, and it is confidently pre- 
seated as in every respect worthy to maintain the high reputation which has rendered it a stand- 
ard authority on this department of medical science. 

ThM ? sift ■**l££«£ ta JS5i , K I S3£ iasfffiSKsr T^xprz 

Fabortona » r'a^wwJh^rSSfftS'. '"«t'e°! ' be that wMcl "Eealfo, the disease, of the arteries 

£.*SB& ^ESL^tbo.rsttcce'ed^amidtbe . te,^,,.^!!^.-^-*- JO* ««..-*«*. 

l$gZ^Z£Z^ , S21?£3£F£Z ^JS ^ comp.ete, a, the great En.tisb 
H lioaei? of sunsery.-ioiidon ia).oe(, Oct. 26, 1S72. ■ treat lse on Surgery of our own time is we can assure 

S^atU™?^^^ ; practitioner -Duolto Quarterly Journal. 



it the alterations and additions ; for, as the author 



rkRUITT (ROBERT), M.R.C.S., §*c. 

^THE PRINCIPLES AND PRACTICE OE MODERN SURGERY. 

A new and revised American, from the eighth enlarged and improved London edition. Illns- 
fratel'th four hundred and thirty -two wood engravings In one ^ ^g™ octavo 
volume of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 W. 
^ it* «nr*ical student or practitioner could practice of surgery are treated and so clearly and 



All that the surgical student or practitioner could 
desire. —Dublin Quarterly Journal. 

It is a most admirable book. We do not know 
when we have examined one with more pleasure.— 
Boston Med. and Surg. Journal. 

In Mr Druitt's book, though containing only some 
geven hundred pages, both the principles and the 



practice oi suigci^ a.^ ^— > ; -- ---- • 

perspicuously, as to elucidate every important topic. 
We aave examined the book most thoroughly and 
can <ay that this success is well merited. His book, 
moreover, possesses the inestimable advantages of 
having the subjects perfectly well arranged and clas- 
sified, and of being written in a style at once clear 
ind succinct.— Am. Journal of Med. Sciences. 



A SET ON (T. J.). 

ON THE DISEASES, INJURIES, AND MALFORMATIONS OF 

THE RECTUM AND ANUS ; with remarks on Habitual Constipation. Second American, 
frSth?fonrthat?«l«ged London edition. With handsome illustrates. In one very 
beautifully printed octavo volume of about 300 pages, cloth, $6 2b. 

T21GEL0 W (HENRY J.), M. D., 

JlJ Professor of Surgery in the Massachusetts Med. College. 

ON TOE MECHANISM OF DISLOCATION AND FRACTURE 
INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- 

dial, and Remote Effect,. With'abont one hnndred illustrations. In one very hand- 

some octavo volume, cloth, $3 50. m im j>* 

It is an admirable practical book in the highest and best sense of the phrase-Won Medical Time, 

ind Gazette, May 18, 1867. 



Henry C. Lea's Publications-— (Surgery). 



29 



I2RYANT [THOMAS), F.R.C.S., 

<*•* . Surgeon to Guy's Hospital. 

THE PRACTICE OF SURGERY. With over Five Hundred En- 

ShTfi °£ ,l°Ji ° ne ,'?; rge ,'" 1 i Ter3 ' H^dsome octavo volume of nearly 1000 pages, 

cloth, ftb lb] leather, raised bands, $7 25. <t „*„i„. d-.z/.-.a^j x 



Again, the author gives us his own practice, his 
own beliefs, and illustrates by his own cases, or those 
treated in Guy's Hospital. This feature adds joint 
em phasis, and a solidity to his statements that inspire 
confidence. Oue feels himself almost by the side of 
the snrgeon, seeing his work and hearing his living 
words The views, etc., of other surgeons are con- 
side' red calmly and fairly, but Mr. Bryant's are 
adopted. Thus the work is not a compilation of 
other writings; it is not an encyclopaedia, but the 
plain statements, on practical points, of a man who 
h.is lived and breathed and had his being in the 
richest surgical experience. The whole profession 
owe a debt of gratitude to Mr. Bryant, for his work 
in their behalf. We are confident that the American 
profession will give substantial testimonial of their 
feeiings towards both author and publisher by 
speedily exhausting this edition. We cordially'and 
heartily commend it to our friends, and think that 
no live surgeon can afford to be without it —Detroit 
Review of Med. and Pharmacy, August, 1S73. 

As a manual of the practice of surgery for the use 
of the student, we do not hesitate to pronounce Mi- 
Bryant's book a first-rate work. Mr. Bryant has a 
good deal of the dogmatic energy which goes with 
the clear, pronounced opinions of a man whose re- 
flections and experience have moulded a character 
not wanting in firmness and decision. At the same 
time he teaches with\|he enthusiasm of one who has 
faith in his teaching; she speaks as one having au- 
thority, and herein lies the charm and excellence of 



{Lately Published.) 
and fairly, yet it is no mere compilation. The book 
combines much of the merit of the manual with the 
merit of the monograph. One may recognize in 
almost every chapter of the ninety-four of which the 
work is made up the acuteness of a surgeon who has 
seen much, and observed closely, and who gives forth 
the results of actual experience. In conclusion we 
repeat what we stated at first, that Mr. Bryant's book 
is one which we can conscientiously recommend both 
to practitioners and students as an admirable work 
—Dublin Journ. of Med. Science, August, 1873. 

Mr. Bryant has long been known to the reading 
portion of the profession as an able, clear, and graphic 
writer upon surgical subjects. The volume before 
us is one eminently upon the practice of surgery and 
not one which treats at length on surgical pathology 
though the views that are entertained upon tnis sub- 
ject are sufficiently interspersed through the work 
for all practical purposes. As a text-book we cheer- 
fully recommend it, feeling convinced that, from the 
subject-matter, and the concise and true way Mr 
Bryant deals with his subject, it will prove a for- 
midable rival among the numerous surgical text- 
books which are offered to the student.— N Y Med 
Record, June, 1S73. 

This is, as the preface states, an entirely new book, 
and contains in a moderately condensed form all the 
surgical information necessary to a general practi- 
tioner. It is written in a spirit consistent with the 
present improved standard of medical and surgical 



Th< 



his wo^rVeTu^Tth; opinions o? XrsXely 1$^-*™*** *""* ° f «****■ A ^ 

OTELLS {J. SOELBERG), 

Professor of Ophthalmology in King's College Hospital &c 

A TREATISE ON DISEASES OF THE EYE. Second American 

from the Third and Revised London Edition, with additions; illnstated with nnmerons 
A few notices of the previous edition are subjoined profession. 



„ „^^„ „, lu uniiciom lavoi. it 

iu tact, a comprehensive and thoroughly practical 
t*eause on diseases of the eye, setting forth the prac- 
tice of the leading oculists of Europe and America 
Kiid .giving the author's own opinions and preferences' 
winch are quite decided and worthv of high consid- 
eration. The third English edition" from which this 
i* taken, having been revised by the author, com- 
prises a notice of all the more recent advances made 
m ophthalmic science. The style of the writer is 



subject that are in the market/ Special" pains "are 
taken to explain, at length, those subjects which are 
particularly difficult of comprehension to the begin- 
ner, as the use of the ophthalmoscope, the interpre- 
tation of its images, etc. The book is profusely and 
ably illustrated, and at the end are to be found 16 
excellent colored ophthalmoscopic figures, which are 
copies oi some of the plates of Liebreich's admirable 
&thi$.— Kansas City Med. Journ., June, 1S74 



£A URENCE [JOHN Z.), F. R. G. S., 

Editor of the Ophthalmic Review, &c. 

A S^ T " B0 , 0K .?J OPHTHALMIC SURGERY, for the use of 

^^^^^^a^S.^'Sr 8 ' 4 - ^—o'usillnstratlons. * 

«££a iorn e rIes'oT h t he m e U y S e,Tnrwn„ e a r a e re t „ „ f u^T ."VT "V"* WMC " *™ MC « ed "» ™*- 

much pressed for time to stud/thecla,"c works on £ ?h f rofes ?«"» •""» ""> appearance of his 

the subject, or those recently published by Stellwn. .-J K ™lume haa been considerably enlarged 

Wells, Bader, and others, Mr. Laurence will move a »„fw Pr ° V<id b , y ">," r \ Vl8io ° and """"ions of its 

safe and trustworthy guide. He has de^L Ihi ^ ™.' S.T^SUan. fS5?~ edi "°" "-"»• 



30 Henry C. Lea's Publications— (Surgery, &c). 



THOMPSON {SIR HENRY), 

«* Surgeon and Professor of Clinical Surgery to University College Hospital. 

LECTURES ON DISEASES OF THE URINARY ORGANS. With 

illustrations on wood. Second American from the Third English Edition. In one neat 

octavo volume. Cloth, $2 25. (Now Ready.) 
My aim has been to produce in the smallest possible compass an epitome of practical knowl- 
edge concerning the nature and treatment of the diseases which form the subject of the work ; 
and I venture to believe that my intention has been more fully realized in this volume than in 
either of its predecessors. — Author 's Preface. 

T>Y THE SAME AUTHOR. 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHBA AND URINARY FISTULA. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 
(Lately Published.) 
T>Y THE SAME AUTHOR. (Just Issued.) 

THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY 

AND TREATMENT. Fourth Edition, Revised. In one very handsome octavo volume of 
355 pages, with thirteen piates, plain and colored, and illustrations on wood. Cloth, $3 75. 

ffAYLOR {ALFRED S.), M.I)., 

■*■ Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital 

MEDICAL JURISPRUDENCE. Seventh American Edition. Edited 

by John J. Reese, M.D., Prcf. of Med. Jurisp. in the Univ. of Penn. In one large 
octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. (Just Issued.) 

In preparing for the press this seventh American edition of the " Manual of Medical Jurispru- 
dence" the editor has, through the courtesy of Dr. Taylor, enjoyed the very great advantage of 
consulting the sheets of the new edition of the author's larger work, " The Principles and Prac- 
tice of Medical Jurisprudence," which is now ready for publication in London. This has enabled 
him to introduce the author's latest views upon the topics discussed, which are believed to bring 
the work fully up to the present time. 

The notes of the former editor, Dr. Hartshorne, as also the numerous valuable references to 
American practice and decisions by his successor, Mr. Penrose, have been retained, with but few 
slight exceptions ; they will be found inclosed in brackets, distinguished by the letters (H.) and 
(P.). The additions made by the present editor, from the material at his command, amount to 
about one hundred pages; and his own notes are designated by the letter (R.). 

Several subjects, not treated of in the former edition, have been noticed in the present one, 
and the work, it is hoped, will be found to merit a continuance of the confidence which it has so 
long enjoyed as a standard authority. 

D7 THE SAME AUTHOR. (Now Ready.) 

THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 

DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 

volumes, cloth, $10 00; leather, $12 00. 
This great work is now recognized in England as the fullest and most authoritative treatise on 
every department of its important subject. In laying it, in its improved form, before the Ameri- 
can profession, the publisher trusts that it will assume the same position in this country. 

DI THE SAME AUTHOR. New Edition— Nearly Ready. 

POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE. Third American, from the Third and Revised English Edition. In one 
large octavo volume of 850 pages. 
This work, which has been so long recognized as a leading authority on its important subject, 
has received a very thorough revision at the hands of the author, and may be regarded as a 
new book rather than as a mere revision. He has sought to bring it on all points to a level 
with the advanced science of the day; many portions have been rewritten, much that was of 
minor importance has been omitted, and every effort made to condense a complete view of the 
subject within the limits of a single volume. Dr. Taylor's position as an expert has brought 
him into connection with nearly all important cases in England for many years. He thus speaks 
with an authority that few other living men possess, while his intimate acquaintance with the 
literature of toxicology on both sides of the Atlantic, renders his work equally adapted as a 
text-book in this country as in Great Britain. 

CONTENTS. 

Poisons. — Absorption and Elimination — Detection — Action — Influence of Habit — Classifica- 
tion of Poisons — Evidence of Poisoning — Diseases resembling Poisoning — Inspection of the Dead 
Body — Objects of Chemical Analysis — Moral and Circumstantial Evidence in Poisoning, Ac. <&c. 

Irritant Poisons. — Mineral Irritants — Acid Poisons — Alkaline Poisons — Non-Metallic Irri- 
tants — Metallic Irritants — Vegetable Irritants — Animal Irritants. 

Neurotic Poisons. — Cerebral or Narcotic Poisons — Spinal Poisons — Cerebro-Spinal Poisons — 
Cerebro-Cardiac Poisons. 






_ J 1 ***^^^ Medicine, &c). 31 

rPUKE {DANIEL HACK), M.D ~ 

-«■ Joint author of ' ' The Manual of Psychological Medicine, ' ' &c 

IL ™ STRATI0]SS 0F THE INFLUENCE OF THE MIND FPO\T 

n LAND FORD (G. FIELD1NGYM^D~FR C P 

T^S fSr^T ^^ caZ **««- «* ^ **«* of St. George's Hospital, &c. 

handsome octavo volume of 471 pages ; cloth, $3 25 * ' D ' Iu ° ne ver J 

*M- *t^^ a — P-^nsive trea- 

sure value to the vJ^ne^^^{J^^^SSSV "^S^ J ™*^*** 
formation, not elsewhere to be found n L acceUible af L^ t fl a PP e , ndl * which affords in- 

be called upon to take action in relatTo^to patients ' P ^ S1Clans who may at any moment 

SSS^^.^'JS^.-SiK ssas Ei^ ; f ^-"^--- -S-^ 

of the mode of examining perfonT suspected of in SffiE '. P f tU1 ' eS f tbe Various forms of mental 

sanity. W e call particular atSXn toSs fe2u?e ftSSr'iShVi *** g °° d - that U ° reader ca » fail 

of the book, as giving it a unique value to the *ene .rdiaa v Sam ^- r r[ > ^r^, 7 t0 th ° Se ^ ivei1 in 

ral practitioner. If we pass from theoretical confide l?7wn»S 6 ^ llsh language or (so far 

rations to descriptions F f the varieties of insanity as RSSSE^^ST^ " " 7 otlie '-*>»*>» 



yymsLow (forbes), £d^cJ^; 

ON OBSCURE DISEASES OF THE BRAIN AND m^npn^o 

. octavo volume of nearly 600 pages, cloth, $4 1 25 g In ° ne hands °**e 

JjEA [HENRY C). 

SUPERSTITION AND FORCE: ESSlYS ONT TRF tta^d m 

LAW, THE WAGER OF BATTLE, THE OMEaI, Iot TOBT ^ let^V^' 

-all-ol^ 

operations of the human mind. Foot-notes Live the on > ^ ™ ana breadth with which he ha! carried 

authority for each statement, showing vast St -ch Mstorv rtSSZS*! """^T ° f tMs re P ul ^e field of 

and wonderful industry. We advise our confrll, f, f 7 [Torture] are such as to preclude our doing 

^gr THE SAME AUTHOR. (Lately PvMUh^L) 

^^^S^^^^^^O^ THE T EM . 

12mo. volume of 516 pp. cloth, $2 75. *^VJ11MUJN1CATI0N. In one large royal 

greater learning" orwi^er tuought" Ve^ubt °inZed I fZ^l P h h enome ?"> n 1 th ^ the head of one of the first 
if any other study of this field cau be compared with ' oririnalh tT^ r* ? the f liter of some of its mo 
this tor clearness, accuracy, and power -Ohilaoo ° nglnal book s--£^<m Athenceum, Jan. 7, 1871 
■w«r. Dec. 1870. " LhlCa 9° j Mr Lea has done great honor to himself and hi 8 

fJiv Le ^' slat \ st ^ork, "Studies in Church History » i ecX Solo XS* , a H dmirab t le ™. rka h « ^as written on 
fully sustains the promise of the first It deals wUh ! «« c . le * lolo S?calaud cognate subjects. We have already 

Cl^v S L b rF S - the Temp ° ral ^-er BenenTof wW-E^ ?S '.'Superstition «« 
Clergy, and Excommunication, the record of which t?p L tnt ™? Hlst ^T, of &ac erdotai Celibacy." 
has a peculiar importance for the English student and I„h ! i ! tvolau \ e ^ fully as admirable in its me- 
•s a chapter on Ancient Law likely fo be regarded as ! fl l S? 1 '^ ^ !° piCS and in the tborougbuesTl 
^ Z Q Sii-SIW-ft- ~ mentio^ofluJh I wffw£ ^^^ 



anal We can hardl, 'V^f-^urnZZToT^ I ^I^™* ™**** 7 ^^n a*uth = 

s^ sh^-n^^ta;^^ ! S"&:-s^ - »— * 



82 



Henry C. Lea's Publications. 



INDEX TO CATALOGUE 



PAGE 
1 



Amferican Journal of the Medical Sciences 
Abstract, Half-Yearly, of the Med. Sciences 
Inatomical Atlas, by Smith and Horner 
Anderson on Diseases of the Skin 
Ashton on the Kectum and Anus . 
Attfield's Chemistry .... 
Ashwell on Diseases of Females . 
Ashhurst's Surgery .... 

Barnes on Diseases of Women 
Bellamy's Surgical Anatomy 
Bryant's Practical Surgery . 
Bloxam's Chemistry • . . . 
Blandford on Insanity .... 
Basham on Renal Diseases . 
Brinton on the Stomach 
Bigelow on the Hip .... 

Barlow's Practice of Medicine 
Bowman's (John E.) Practical Chemistry 
Bowman's (John E.) Medical Chemistry 
Bumstead on Venereal . . • ■ 
Bumstead and Cullerier's Atlas of Venereal 
Carpenter's Human Physiology . 
Carpenter's Comparative Physiology . . 
Carpenter on the Use and Abuse of Alcohol 
Carson's Synopsis of Materia Medica . 
Chambers on Diet and Regimen . 
Chambers's Restorative Medicine 
Christison and Griffith's Dispensatory 
Churchill's System of Midwifery . 
Churchill on Puerperal Fever 
Condie on Diseases of Children . 
Cooper's (B. B.) Lectures on Surgery . 
Cullerier's Atlas of Venereal Diseases 
Cyclopedia of Practical Medicine . 
DaltOD's Human Physiology . 
Davis' Clinical Lectures 
De Jongh on Cod-Liver Oil . 
Dewees on Diseases of Females . 
Dewees on Diseases of Children . 
D mitt's Modern Surgery 
Dunglison's Medical Dictionary . 
Dunglison's Human Physiology . 
Dunglison on New Remedies . . 

Ellis's Medical Formulary, by Smith . 
Erichsen's System of Surgery 
Fenwick's Diagnosis .... 
Flint on Respiratory Organs . 

Flint on the Heart 

Flint's Practice of Medicine . 

Flint's Essays 

Flint on Phthisis . 

Fownes's Elementary Chemistry . 

Fox on Diseases of the Stomach . 

Fuller on the Lungs, &c. . • • 

Green's Pathology and Morbid Anatomy 

Gibson's Surgery . . • • • 

G luge's Pathological Histology, by Leidy 

Galloway's Qualitative Analysis . 

Gray's Anatomy . • • • 

Griffith's (R. B.) Universal Formulary 

Gross on Foreign Bodies in Air-Passages 

Gross's Principles and Practice of Surgery 

Guersant on Surgical Diseases of Children 

Hamilton on Dislocations and Fractures 

Hartshorne's Essentials of Medicine . 

eartshorne's Conspectus of the Medical Sciences 

Hartshorne's Anatomy and Physiology 

Heath's Practical Anatomy . 

Hoblyn's Medical Dictionary 

Hodge on Women 

Hodge's Obstetrics 

Hodges' Practical Dissections . . 
Holland's Medical Notes and Reflections 
Horner's Anatomy and Histology 
Hudson on Fevers .... 

Hill on Venereal Diseases . 
Hillier's Handbook of Skin Diseases 
Jones and Sieveking's Pathological Anatomy 
Jones (C. Handheld) on Nervous Disorders 



dged 



Kirkes' Physiology .... 
Knapp's Chemical Technology . 
Lea's Superstition and Force 
Lea's Studies in Church History . 

Lee on Syphilis 

Lincoln on Electro-Therapeutics . 

Leishman's Midwifery .... 

La Roche on Yellow Fever . 

La Roche on Pneumonia, &c. 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye .... 

Laycock on Medical Observation . 

Lehmann's Physiological Chemistry, 2 vols. 

Lehmann's Chemical Physiology . 

Ludlow's Manual of Examinations 

Lyons on Fever ..... 

Maclise's Surgical Anatomy . 

Marshall's Physiology .... 

Medical News and Library . 

Meigs's Lectures on Diseases of Women 

Meigs on Puerperal Fever 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Montgomery on Pregnancy . . • 

Neill and Smith's Compendium of Med. Science 

Neligan's Atlas of Diseases of tl 3 Skin 

Neligan on Diseases of the Skin 

Obstetrical Journal .... 

Odling's Practical Chemistry 

Pavy on Digestion ...» 

Pavy on Food 

Parrish's Practical Pharmacy 
Pirrie's System of Surgery . . • 
Pereira's Mat. Medica and Therapeutics, abric 
Quain and Sharpey's Anatomy, by Leidy 
Roberts on Urinary Diseases . • 
Ramsbotham on Parturition . 
Rigby's Midwifery •■'•■•• 
Royle's Materia Medica and Therapeutics 
Swayne's Obstetric Aphorisms . 
Sargent's Minor Surgery . • • 
Sharpey and Quain' s Anatomy, by Leidy 
Skey's Operative Surgery 
Slade on Diphtheria .... 
Smith (J. L.) on Children . ; • 
Smith (H. H.) and Horner's Anatomical Atlas 
Smith (Edward) on Consumption . 
Smith on Wasting Diseases *. Children 
Stille's Therapeutics 
Sturges on Clinical Medicine 
Stokes on Fever . . • • • 
Tanner's Manual of Clinical Medicine . 
Tanner on Pregnancy . 
Taylor's Medical Jurisprudence • • 
Taylor's Principles and Practice of Med Jurisp 
Taylor on Poisons . . • . > ■ 
Tuke on the Influence of the Mind 
"Thomas on Diseases of Females . 
Thompson on Urinary Organs 
Thompson on Stricture . 
Thompson on the Prostate 
Todd on Acute Diseases .... 
Walshe on the Heart . 
Watson's Practice of Physic . 

Wells on the Eye 

West on Diseases of Females 

West on Diseases of Children . . 

West on Nervous Disorders of Children 

What to Observe in Medical Cases 

Williams on Consumption . 

Wilson s Human Anatomy . 

Wilson on Diseases of the Skin . . 

Wilson's Mates on Diseases of the Skin 

Wilson's Handbook of Cutaneous Medici 

Winslow on Brain and Mind 

Wohler's Organic Chemistry 

Winckel on Childbed 

Zeissl on Venereal .... 



For " The Obstetrical Journal," Five Dollars a year, see p, 



22. 



906 



